Exam 2

A nurse is teaching a childbirth preparation class about the discomfort of labor. What is the greatest influence on the perception of pain for a woman in labor?

Tension on the client

Latent stage of labor

0-3 cm cervical dilation and effacement

A client in labor is having an indwelling urinary catheter inserted. What should the nurse plan to do to prevent late decelerations of the fetal heart rate during this procedure? 1 Position both the client's legs simultaneously. 2 Urge the client to take deep breaths frequently. 3 Place a rolled towel under the client's right hip. 4 Loosen the transducer belts around the client's abdomen.

3 Place a rolled towel under the client's right hip. Elevating the right hip displaces the uterus to the left, improving placental perfusion and prevents supine hypotension caused by pressure on the vena cava and its associate late fetal heart rate decelerations.

Active stage of labor

4-7 cm cervical dilation

Transition stage of labor

8-10 cm cervical dilation feelings of fatigue, discouragement, nausea.

What is a positive NST?

Accelerations with movement and a baseline variability of 5-15 beats/min indicate fetal well-being.

Nonstress test (NST)

An assessment method by which the reaction (or response) of the fetal heart rate to fetal movement is evaluated.

What medications would the nurse identify as being used to induce labor in pregnant clients? Select all that apply. Oxytocin Ergonovine Carboprost Misoprostol Dinoprostone

Oxytocin Misoprostol Dinoprostone

Variable decelerations are associated with

cord compression during a CST or during labor

Late decelerations are associated with

uteroplacental insufficiency

A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication should the nurse anticipate when assessing the character of the client's amniotic fluid? 1 Cord prolapse 2 Placenta previa 3 Maternal sepsis 4 Abruptio placentae

Answer: 3 Maternal sepsis Prolonged rupture of membranes of more than 18 hours increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.

Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration. A. Elevating the legs B. Repositioning the client from side to side C. Increasing the rate of intravenous infusion D. Administering oxygen by way of facemask

B. Repositioning the client from side to side Rationale: A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation. Increasing the rate of intravenous fluid administration and elevating the legs are interventions for placental perfusion problems and do not affect cord compression.

Which fetal heart rate (FHR) finding would concern the nurse during labor? a. One that does not slow during contractions b. One that ranges form 130-140 bpm c. One that drops to 90 beats per minute during a contraction d. One that drops 100 beats per minute after the peak of the contraction

d. One that drops 100 beats per minute after the peak of the contraction Late decelerations begin during the peak of a contraction and continue after the contraction has ended. FHR does not always drop during a contraction. A drop to 90 bpm indicates head compression which is normal during a contraction. The FHR should return to baseline at the same time the contraction ends

Early decelerations are associated with

fetal head compression during a contraction stress test (CST) or during labor

During labor tachycardia in the baby indicates

fetal hypoxia, maternal fever, infection, or some other factor that is stressing the fetus