Intrapartum

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1, 2, 3, and 5 are correct 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2. The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3. The client's age should also be noted before the physical assessment is begun. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth—should also be noted before a physical assessment is begun.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconium-stained fluid. The client needs to be assessed

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1. Bulging perineum. 2. Increased bloody show. 4. Uncontrollable urge to push. 1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enter the second stage of labor. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push.

On examination of a full-term primipara, a labor nurse notes active labor, right occiput anterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines.

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

1. Fetal heart rate. 2. Contraction pattern. 4. Vital signs. 1. The nurse should assess the fetal heart before reporting the client's status to the healthcare provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 4. The nurse should assess the woman's vital signs before reporting her status.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous infusion rate.

1. Give the woman a back rub. 2. Assist the woman with her breathing.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. Left occipital anterior (LOA). The nurse's findings upon performing Leopold maneuvers indicate that the fetus is in the left occiput anterior (LOA) position—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1. The relationship between the decelerations and the labor contractions. The relationship between the decelerations and the contractions will determine the type of deceleration pattern Decelerations are defined by their relationship to the contraction pattern. It is essential that the nurse determine which of the three types of decelerations is present. Early decelerations mirror contractions, late decelerations develop at the peak of contractions and return to baseline well after contractions are over, and variable decelerations can occur at any time and are often unrelated to contractions.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2. Evaluate the progress of labor. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2. Have the woman breathe into a bag. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Her cervix has dilated from 2 to 4 cm. Once the cervix begins to dilate, a client is in true labor.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Ischial spines. Station is assessed by palpating the ischial spines

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half-hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."

3. "I took a shower about a half-hour ago. The contractions hurt more than they did before." This response indicates that the labor contractions are increasing in intensity.

Does the nurse know that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tension & pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Knowledge learned at childbirth education classes helps to break the fear-tension & pain cycle. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

3. Provide direct sacral pressure. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. Whenever a laboring woman complains of severe back labor, it is very likely that the baby is lying in the occiput posterior position. Every time the woman has a contraction, the head is pushed into the coccyx. When direct pressure is applied to the sacral area, the nurse is providing counteraction to the pressure being exerted by the fetal head.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3. Right upper quadrant (RUQ). Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. it does provide the information that the sacrum is felt toward the mother's right. Because this baby is in the sacral presentation and the back is toward the right, the best location for the fetal monitor is in the RUQ, at the level of the fetal back.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. 10 cm dilated, 100% effaced, and +5 station. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

4. Monitor for signs of rectal pressure. Monitoring for rectal pressure is appropriate at this time.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. Vaginal examination. A vaginal examination will provide the nurse with the best information about the status of labor

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

Cover the woman's perineum with a sheet. The woman's privacy should be maintained while she is resting.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

The client is exhibiting an expected behavior for labor The woman is showing expected signs of the active phase of labor