Maternity-Intrapartum
An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? Light green, with no odor Clear and dark amber in color Thick and white, with no odor Pale straw in color, with flecks of vernix
4 Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white; this could be an indication of infection.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? Maternal fatigue Coordinated uterine contractions Progressive changes in the cervix Persistent nonreassuring fetal heart rate
4 Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? "It is the application of pressure to the sacrum to relieve a backache." "It is a form of biofeedback to enhance bearing-down efforts during delivery." "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest.
3 Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? Contact the obstetrician. Continue to monitor the client. Report the FHR to the anesthesiologist. Prepare for imminent delivery of the fetus.
2 The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? Variability Accelerations Early decelerations Variable decelerations
4 Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. -Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the primary health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? Bear down. Breathe rapidly. Hold your breath. Push with each contraction.
2 During a precipitous labor, when the infant's head crowns the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus.
Which assessment finding after an amniotomy should be conducted first? Cervical dilation Bladder distention Fetal heart rate pattern Maternal blood pressure
3 Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.
The nurse is preparing to care for a client in labor. The primary health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? An IV infusion of antibiotics Placing the client on complete bed rest Continuous electronic fetal monitoring Placing a code cart at the client's bedside
3 Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.
A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Back pain Heavy vaginal bleeding Increase in fundal height Hard, board-like abdomen Persistent abdominal pain Early deceleration on the fetal heart monitor
3, 4, 5 The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The contractions are regular. The membranes have ruptured. The cervix is dilated completely. The client begins to expel clear vaginal fluid. The Ferguson reflex is initiated from perineal pressure.
3, 5 The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. Less pressure on her cervix Decreased number of contractions Increased efficiency of contractions The need for increased maternal blood pressure monitoring The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
3, 5 -Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. -Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. -Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? Assessing the mother's reflexes Taking the mother's temperature Taking the mother's apical pulse Monitoring the mother's blood pressure
4 A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.
The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? Administer oxygen by face mask. Clear and maintain an open airway. Administer magnesium sulfate intravenously. Assess the blood pressure and fetal heart rate.
2 The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? Ambulation Rest between contractions Change positions frequently Consume oral food and fluids
2 The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. -Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. -Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? Hourly Every 15 minutes Every 30 minutes Before each contraction
2 The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen. The nurse documents these observations as signs of which condition? Hematoma Uterine atony Placenta previa Placental separation
4 As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? "I won't be in labor until my baby drops." "My contractions will be felt in my abdominal area." "My contractions will not be as painful if I walk around." "My contractions will increase in duration and intensity."
4 True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
1 If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned onto her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is then applied to the mother.
A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? Measure fundal height. Attach electronic fetal monitoring. Prepare the client for a possible cesarean section. Visually examine the perineum and vaginal opening.
1 Measuring fundal height is least appropriate because it should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. -The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the primary health care provider. -A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.
The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. Petechiae Hematuria Increased platelet count Prolonged clotting times Oozing from injection sites Swelling of the calf of 1 leg
1, 2 , 4, 5 DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. -Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. -The presence of petechiae, hematuria, and oozing from injection sites are signs associated with DIC. Swelling and pain in the calf of 1 leg are more likely to be associated with thrombophlebitis.
The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. A primigravida with abruptio placenta A primigravida who delivered a 10-lb infant 3 hours ago A gravida 2 who has just been diagnosed with dead fetus syndrome A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension
1, 3, 5 In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.
The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? Increased urinary output A fetal heart rate of 90 beats/minute 3 contractions occurring within a 10-minute period Adequate resting tone of the uterus palpated between contractions
2 A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. -The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures. Prepare the client for an amniotomy. Promote ambulation every 30 minutes. Monitor the oxytocin infusion closely.
1 -Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. -An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. -A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Forceps delivery Schultz presentation Hypotonic contractions Weak bearing-down efforts
1 Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. -Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. -Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.
The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. Keep the room semi-dark. Initiate seizure precautions. Pad the side rails of the bed. Avoid environmental stimulation. Allow out-of-bed activity as tolerated.
1, 2, 3, 4 Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. -In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.
During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Stimulate the labor process. Prevent dehydration and hypoxemia. Avoid the necessity of a cesarean section. Eliminate the need for analgesic administration.
2 A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. -These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? Notify the primary health care provider. Discontinue the infusion of oxytocin. Place oxygen on at 8 to 10 L/minute via face mask. Contact the client's primary support person(s) if not currently present.
2 The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. -Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. -Contacting the client's primary support person(s) is not the priority action at this time.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? Notify the primary health care provider (PHCP). Continue monitoring the fetal heart rate. Encourage the client to continue pushing with each contraction. Instruct the client's coach to continue to encourage breathing techniques.
1 A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? The client's fear The client's fatigue The client's inability to control the situation The client's inability to cope with the situation
1 The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. There are no data in the question to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience.
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. Age 54 years Body mass index of 28 Previous difficulty with fertility Administration of oxytocin for induction Potassium level of 3.6 mEq/L (3.6 mmol/L)
1, 2, 3 Risk factors that increase a woman's risk for dysfunctional labor include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. -Age 54 years is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. -A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? Soft abdomen Uterine tenderness Absence of abdominal pain Painless, bright red vaginal bleeding
2 Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? Supine position with a wedge under the right hip Trendelenburg's position with the legs in stirrups Prone position with the legs separated and elevated Semi-Fowler's position with a pillow under the knees
1 -Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. -best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. -Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask. Place the mother in a supine position. Increase the rate of the oxytocin intravenous infusion. Document the findings and continue to monitor the fetal patterns.
1 -Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. -The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. -The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? Hemoglobin of 11 g/dL (110 mmol/L) Fetal heart rate of 180 beats per minute Maternal pulse rate of 85 beats per minute White blood cell count of 12,000/mm3 (12 × 109/L)
2 A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. -The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over pre-pregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. -White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of, 11,000-15,000/mm3 up to 18,000/mm3 -During the immediate postpartum period, the white blood cell count may be 25,000-30,000/mm3 because of increased leukocytosis that occurs during delivery.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? Notify the primary health care provider of the findings. Reposition the mother and check the monitor for changes in the fetal tracing. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
4 Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? Identify the types of accelerations. Assess the baseline fetal heart rate. Determine the intensity of the contractions. Determine the frequency of the contractions.
2 Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.
The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? Noting whether the heart rate is greater than 140 beats/minute Placing the diaphragm of the Doppler on the mother's abdomen Palpating the maternal radial pulse while listening to the FHR Performing Leopold's maneuvers first to determine the location of the fetal heart
3 The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. -Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the 2 heart rates.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Uterine rigidity Uterine tenderness Severe abdominal pain Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age
4, 5, 6 -Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. -The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. -Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation, as the blood penetrates the myometrium and causes uterine irritability.
The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? No accelerations of fetal heart rate (FHR) Moderate variability present Variable decelerations present FHR of 170 to 180 beats/minute
2 Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression.
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? Prepare the client for an ultrasound. Obtain equipment for a manual pelvic examination. Prepare to draw a hemoglobin and hematocrit blood sample. Obtain equipment for external electronic fetal heart rate monitoring.
2 Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. -->Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. -A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. -Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.
