Maternity PrepU Chapter 14

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?

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

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess the amount of cervical dilation (dilatation).

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?

Inspect the perineum.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?v

Turn her or ask her to turn to her side.

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you."

Which neonatal assessment is the highest priority if the mother received meperidine during labor?

Respiratory rate

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 seconds

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?

Ambulate only with assistance from the nurse or caregiver.

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications.

The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first?

Assess blood pressure.

The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?

Assess return of sensory and motor functions to the lower extremities.

A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the narcotic. How should the nurse respond to the request?

"Your phase of labor makes giving another dose unsafe."

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

Anxiety can slow down labor and decrease oxygen to the fetus.

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

Clear to straw-colored fluid

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

Fetal status

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

Practicing effleurage on the abdomen

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the nitrazine paper?

blue

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage.

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?

every 15 minutes

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first."

Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide?

"It is important to try to urinate every 2 hours because you might not feel the urge."

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification?

"The client reports a pain level of 8. She has a low pain tolerance."

The nurse is reviewing the nursing care plan with a woman during a prenatal visit. What action(s) in the plan is to decrease the woman's pain level during labor? Select all that apply.

discussion about pain relief measures prenatally using a nonpharmacologic method along with needed pharmacologic methods continuous labor support by a doula or trained nurse explaining the process and procedures to decrease anxiety and apprehension

The nurse is monitoring the electronic fetal heart rate monitor and notes the following: variable V-shaped decelerations in the fetal heart rate (FH)R lasting about 30 seconds, accelerations of about 5 beats/min before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize?

Help the woman change positions

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute.