Maternity - Ch 10. Nursing Care During Labor and Birth

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? a. Help the woman change positions. b. Obtain assistance to check for a compressed umbilical cord. c. Prepare the woman for an emergency cesarean birth. d. Document the finding.

a. Help the woman change positions.

As a woman enters the second stage of labor, which would the nurse expect to assess? a. feelings of being frightened by the change in contractions b. reports of feeling hungry and unsatisfied c. falling asleep from exhaustion d. expressions of satisfaction with her labor progress

a. feelings of being frightened by the change in contractions

The maternal health nurse determines a woman who just arrived on the unit is experiencing imminent birth. Which intervention is the nurse's priority? a. Perform hand hygiene. b. Call for help. c. Notify the health care provider. d. Don clean gloves.

b. Call for help.

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? a. Rubbing the client's legs b. Placing a wedge under the hips c. Providing a paper bag d. Massaging the client's lower back

b. Placing a wedge under the hips

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? a. "The client states that she is having heavy bleeding." b. "When ambulating the client to the bathroom, a gush of red blood was noted." c. "The client has saturated three sanitary napkins in the past 4 hours." d. "The client has lost 100cc of blood from what I approximate on her clothing."

c. "The client has saturated three sanitary napkins in the past 4 hours."

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? a. boggy, soft uterus b. uterus becoming discoid shaped c. sudden gush of dark blood from the vagina d. shortening of the umbilical cord

c. sudden gush of dark blood from the vagina Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? a. Test a sample of amniotic fluid for protein. b. Ask her to bear down with the next contraction. c. Elevate her hips to prevent cord prolapse. d. Assess fetal heart rate for fetal safety.

d. Assess fetal heart rate for fetal safety.

The client may spend the latent phase of the first stage of labor at home unless which occurs? a. The client passes the bloody show b. The contractions vary in length and intensity c. The client begins back labor d. The client experiences a rupture of membranes

d. The client experiences a rupture of membranes Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique? a. "Inhale through your nose and exhale through pursed lips." b. "Inhale and exhale through your mouth about 4 times in 5 seconds." c. "Forcefully exhale every so often after inhaling and exhaling through your mouth." d. "Take a cleansing breath before but not after each contraction."

a. "Inhale through your nose and exhale through pursed lips."

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? a. A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. b. Explain that you will have to call the physician and get an order to leave the fetal monitor off. c. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. d. Tell her that it is her decision, but that she will be placing herself and her baby at grave risk.

a. A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? a. Assess and reposition the woman. b. Notify the registered nurse. c. Notify the health care provider. d. Wait 2 minutes to review another tracing.

a. Assess and reposition the woman. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? a. Continue to monitor the client and the fetal heart rate.. b. Promptly inform the primary care provider. c. Reposition the client. d. Advocate for the client to have a vaginal examination.

a. Continue to monitor the client and the fetal heart rate.. As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary.

The nurse is admitting a woman in labor to the labor and delivery unit. Which assessment finding(s) indicates to the nurse that the woman is in the second stage of labor? Select all that apply. a. The cervix is dilated 6 cm. b. The contractions last 50 to 60 seconds. c. The mother reports pelvic pressure. d. The fetal heart rate is 144 beats/min. e. The membranes are ruptured.

a. The cervix is dilated 6 cm. b. The contractions last 50 to 60 seconds.

Which psychosocial state is anticipated when the client enters the active phase of labor? a. The client will become more quiet and introverted. b. The client will become angry and begin to scream. c. The client will become more talkative and excited about the birth. d. The client will become tired and want the process over.

a. The client will become more quiet and introverted. The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.

Which action is a priority when caring for a woman during the fourth stage of labor? a. assessing the uterine fundus b. offering fluids as indicated c. encouraging the woman to void d. assisting with perineal care

a. assessing the uterine fundus During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? a. encouraging the woman to push when she has a strong desire to do so b. alleviating perineal discomfort with the application of ice packs c. palpating the woman's fundus for position and firmness d. completing the identification process of the newborn with the mother

a. encouraging the woman to push when she has a strong desire to do so During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? a. Help the woman to sit up in a semi-Fowler's position. b. Turn her or ask her to turn to her side. c. Administer oxygen at 3 to 4 L by nasal cannula. d. Ask her to pant with the next contraction.

b. Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. variable decelerations b. prolonged decelerations c. early decelerations d. accelerations

b. prolonged decelerations Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? a. notify the health care provider b. reposition the client on either side c. palpate for bladder fullness d. do nothing, this is benign

b. reposition the client on either side Deceleration may be related to compression on the maternal abdominal aorta and inferior vena cava and repositioning the woman to either her right or left side will remove the pressure and allow the blood flow to resume. If this is not effective then the nurse would look for other potential causes such as an infusion of oxytocics. If this is unsuccessful the RN and health care provider needs to be notified immediately. The fetus is not getting enough oxygen and needs intervention. Palpating for bladder fullness would not be appropriate at this time. This is a serious situation developing and needs prompt intervention.

In the labor and delivery unit, which is the best way to prevent the spread of infection? a. Use sterile gloves b. Limit vaginal examinations c. Complete hand hygiene d. Provide clean gloves in the room

c. Complete hand hygiene Hand hygiene remains the best way to prevent the spread of infection. It is appropriate to use sterile gloves for invasive procedures and limit vaginal examinations as much as possible. Providing clean gloves is also important when there is exposure to blood and body secretions.

Which assessment finding is most important as labor progresses? a. The client is remaining in control of emotions. b. Labor is completed within 18 hours. c. The uterus relaxes completely between contractions. d. The pulse and respirations rise with the work of labor.

c. The uterus relaxes completely between contractions. It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.

At what time is the laboring client encouraged to push? a. When the nurse wants the client to push b. When the health care provider has arrived c. When the cervix is fully dilated d. When the fetal head can be seen

c. When the cervix is fully dilated To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? a. having the client breathe with contractions b. providing one-to-one support c. encouraging the woman to ambulate d. urging her to focus on one contraction at a time

c. encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? a. every 5 minutes b. every 10 minutes c. every 15 minutes d. every 20 minutes

c. every 15 minutes

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor? a. every 2 to 4 hours b. every 45 to 60 minutes c. every 15 to 30 minutes d. every 10 to 15 minutes

c. every 15 to 30 minutes During the active phase of labor, FHR is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor. The woman's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after ruptured membranes. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active and transition phases. Contractions are assessed every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 15 minutes during transition.

A client who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed? a. preeclampsia b. premature labor c. placenta previa d. multiple births

c. placenta previa

A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? a. leakage from the perineum when the client coughs b. greenish fluid noted on the client's underwear c. a positive bacterial culture d. a positive nitrazine test

d. a positive nitrazine test

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a. a shallow deceleration occurring with the beginning of contractions b. variable decelerations, too unpredictable to count c. fetal baseline rate increasing at least 5 mm Hg with contractions d. fetal heart rate declining late with contractions and remaining depressed

d. fetal heart rate declining late with contractions and remaining depressed Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? a. providing pain relief for the mother b. koala care c. making sure the significant other holds the infant shortly after birth d. kangaroo care

d. kangaroo care

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? a. Check the fetal heart rate. b. Perform a vaginal exam. c. Notify the primary care provider immediately. d. Change the linen saver pad.

a. Check the fetal heart rate. When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? a. respiratory depression b. urinary retention c. abdominal distention d. hyperreflexia

a. respiratory depression

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? a. Check the pH to ensure the fluid is amniotic fluid. b. Prepare to administer an antibiotic. c. Notify the health care provider about possible meconium. d. Check the maternal heart rate.

c. Notify the health care provider about possible meconium.