Intrapartum

The nurse is caring for a multigravida in active labor with a fetus in a frank breech presentation. The nurse should notify the primary care provider if the nurse observes:

fetal bradycardia at any time during the labor process. Explanation: The client with a breech presentation needs to be carefully monitored for fetal distress or fetal bradycardia, which is often associated with umbilical cord compression.

The health care provider (HCP) prescribes intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which interval?

every 30 minutes during the active phase The first stage of labor is categorized into three phases: latent, active, and transition. During the active stage of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart rate such as bradycardia, tachycardia, or decelerations in a low risk labor. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring is usually performed every 1 hour because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 minutes because the client is getting closer to the birth of the baby. Pushing occurs in stage II of labor, and monitoring continues to occur every 5 to 15 minutes.

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?

Complete uterine rupture

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.

Correct response: Increment. Acme. Decrement. Relaxation.

33s The nurse performs the initial assessment and reports the following findings to the physician: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage of labor?

Active Explanation: Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor. Active labor is characterized by cervical dilation of 4-7 cm. The regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and is at -1 station. Second refers to the second stage of labor (begins when the cervix is 10 cm dilated), which this client is not yet experiencing. Latent phase is characterized by the onset of regular contractions and cervical dilation of 0-4 cm. Third refers to the third stage of labor, which is the time between birth and the completed birth of the placenta.

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first?

Turn off the oxytocin infusion. The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first?

Document findings on the woman's medical record, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean section.

For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:

exhaustion. The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as dehydration. Hypotonic contractions, which are painful but ineffective, may be occurring. Oxytocin augmentation may be necessary. Chills and fever are manifestations of an infection and are not associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of intravenous fluids administered if the client is experiencing hemorrhage or shock. It is not associated with prolonged latent phase. The client's membranes are intact, so it would be difficult to assess meconium staining of the fluid. Meconium-stained fluid is associated with fetal distress, and this fetus appears to be in a healthy state, as evidenced by a fetal heart rate within normal range and good variability.

A client with a full-term pregnancy is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?

"Pain from the dilation or stretching of the cervix." Explanation: In the first stage of labor the primary source of pain is from the dilation of the cervix. Hypoxia of the contracting uterine muscles; distension of the vagina and perineum; and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.

The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next?

Administer oxygen at 8 to 10 L by mask. Explanation: Late decelerations signal poor placental perfusion. Therefore, oxygen should be administered at 8 to 10 L by mask to improve fetal hypoxia. The nurse should also stop the oxytocin infusion, turn the client onto her side, and report the pattern to the health care provider.

A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?

Document fetal well-being. Explanation: Accelerations that are episodic and occur during fetal movement demonstrate fetal well-being. Turning the client to the left side, applying oxygen by face mask and notifying the HCP are interventions used for late and variable decelerations indicating the fetus is not tolerating the induction process well.

Which finding is the most serious adverse effect associated with oxytocin administration during labor?

Tetanic contractions

A physician decides to artificially rupture a client's membranes. After this procedure, the nurse checks the fetal heart tones to:

assess for fetal bradycardia. Explanation: After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

nurse is caring for a client in labor. Which assessment finding indicates fetal distress?

Fetal blood pH less than 7.2 Explanation: A fetal blood pH less than 7.2 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.2 to 7.3 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. Lack of meconium staining, early decelerations in fetal heart rate during contractions, and an increase in fetal heart rate with fetal scalp stimulation are all normal findings.

Which nursing action is required before a client in labor receives an epidural anesthetic?

Give a fluid bolus of 500 ml. One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.

Which is the priority of care for the nulliparous client who is in the active phase of the first stage of labor?

Implementing nonpharmacologic measures for pain relief The active phase of labor may last up to 6 hours for the nulliparous woman. Nonpharmacologic measures for pain relief should be tried before pharmacologic measures, as this stage of labor can last for quite some time before intensifying. Respecting the client's privacy is a self-esteem need, which prioritizes lower than pain relief. Providing information and education are important but will not prioritize higher than the client's physiologic need for pain relief.

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time?

Preparing for immediate delivery Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Although placing the client in bed, checking for ruptured membranes, and providing comfort measures are applicable interventions, the priority is immediate delivery for this client.

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful?

Stand next to her at the side of the bed. The client is alone and is progressing well in labor, as evidenced by her restless behaviors. She is refusing analgesia but will benefit from the 1:1 nursing care model if she is aware that the nurse is attending her at the bedside. Standing behind her will not provide a sense of nursing presence. Turning up the music or turning on the television is not appropriate unless the client requests them as a distracter.

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy The client who has had 3 prior births and has polyhydraminios has the potential for uterine atony and would be most at risk for a postpartum hemorrhage. The client at 34 weeks with mild pregnancy-induced hypertension would be at minimal risk because the uterus is not extraordinarily distended at this gestation. The gravida 4 para 0 client, who has diet-controlled gestational diabetes, has a risk of hemorrhage from being induced, but her uterus should be able to contract appropriately after the birth as long as there is no history of macrosomia. A history of genital herpes is not a risk factor for a postpartum hemorrhage.

The nurse is caring for a multigravida in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. The nurse should:

continue to monitor the client and fetus. Explanation: Early decelerations are decelerations that mirror the contraction pattern. They are caused by pressure on the fetal skull and are not considered an ominous sign. The nurse should continue to monitor the client and fetus. Early decelerations are common during the second stage of labor. Turning the client to the left side is not warranted.

A 30-year-old multigravida pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when she says that an electronic monitor performs which function?

ensures a more comfortable atmosphere for the client and labor Explanation: Clients who have external or internal fetal monitoring commonly experience greater discomfort because of the equipment. Plus, the client is less mobile with the monitoring belts in place. Continuous electronic fetal monitor allows for fetal heart rate assessment throughout the process of labor, not just after analgesia administration. When twins are present, both fetal heart rates may be monitored simultaneously.

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise?

Allowing the client to ambulate as tolerated Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.

Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client is irritable and has had some nausea with one episode of vomiting. The client is most likely experiencing:

transition phase of labor. Explanation: Irritability, nausea, vomiting, and often the urge to push are all signs that the client is beginning the transition phase of labor that occurs when the client is 8 to 10 cm dilated. A multigravid client generally progresses more rapidly than a primigravid client does. Therefore, it would not be unusual for a client's cervix to dilate from 5 to 7 cm or more within a 2-hour period.

The assessment of a multigravida client reveals that client is 5 cm dilated, 60% effaced, 0 station, vertex presenting in the left occipito posterior (LOP) position. Which of the following can the nurse expect while providing care during labor and birth?

Back labor Posterior positions generally cause more discomfort for the laboring woman because the rotation of the fetal head puts pressure on the sacral nerves, causing sharp pain.

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first?

Check the status of the fetal heart rate.

29s A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for birth, which nursing intervention is most appropriate?

Applying gentle pressure to the baby's head Explanation: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. No one should ever pull at the neonate's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties.

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?

Early decelerations Explanation: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in the FHR that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the FHR that are normally caused by fetal movements and uterine contractions.