NU309 Chapter 15 Labor & Birth
When the client in the transition phase of labor experiences dizziness and tingling in the fingers and around the mouth from hyperventilation, the client is anticipated to be in: A. respiratory alkalosis. B. metabolic alkalosis. C. respiratory acidosis. D. metabolic acidosis.
A. respiratory alkalosis. (The client experiencing hyperventilation blows off CO2 and thus places herself in alkalosis. Because it occurs from the respiratory system, it is termed respiratory alkalosis. The other options are incorrect.)
Which method does the nurse use to determine fetal presentation, position, and attitude? A. Assess location of fetal kicks. B. View on an ultrasound. C. Utilize Leopold maneuvers. D. Complete a vaginal examination.
C. Utilize Leopold maneuvers. (Leopold maneuvers are a noninvasive method of assessing fetal presentation, position, and attitude by placing hands on the maternal abdomen and locating fetal body parts. Ultrasounds are not done by nurses and not typically done at this stage of pregnancy. Assessing fetal kicks and conducting a vaginal examination will not provide accurate data.)
Assessment of a client in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. latent phase of the first stage. B. active phase of the first stage. C. pelvic phase of the second stage. D. early phase of the third stage.
A. latent phase of the first stage. (The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the pregnant client. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.)
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? A. a blood culture to note any infection of the blood B. a urine culture to rule out a urinary tract infection C. an ultrasound to determine fetal age D. a urine dipstick test to check for protein
D. a urine dipstick test to check for protein (Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.)
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? A. -5 B. 0 C. +1 D. +4
D. +4 (As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.)
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 (Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension. Rubbing the legs or massaging the back can relax the client between intense contractions but those actions do not prevent a complication. Providing a paper bag prevents hyperventilation typically caused by pattern breathing.)
Assessment of a pregnant client reveals that she has been having frequent contractions. Which question would be helpful to ask next? A. "Are the contractions increasing in frequency and intensity?" B. "When were the first contractions felt?" C. "Can you rate the pain on a scale of 1 to 10?" D. "Can you feel your abdominal muscles tighten?"
A. "Are the contractions increasing in frequency and intensity?" (The nurse's next action is to assess whether the contractions signal the beginning of labor or Braxton-Hicks contractions. Braxton-Hicks contractions occur throughout pregnancy as painless uterine contractions. As labor approaches, contractions become more consistent and increase in intensity. Rating the pain of contractions can help the health care provider decide if there is a need for pain medication or an epidural. It is not as important to know when the contractions started; rather, it's the frequency at which the contractions are occurring that indicates if labor has begun. The actual physical feeling of the muscles tightening across the abdomen is not used medically to determine the beginning of labor.)
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? A. Acceleration of at least 15 bpm for 15 seconds B. Increase in variability by 27 bpm C. Deceleration followed by acceleration of 15 bpm D. Decrease in variability for 15 seconds
A. Acceleration of at least 15 bpm for 15 seconds (A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.)
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? A. The cervix is softening B. The uterus is relaxing C. The cervix is dilating D. The perineum is relaxing
A. The cervix is softening (The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.)
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? A. "She is in active labor; she is progressing at this point and we will keep you posted." B. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." C. "She is still in early latent labor and has much too long to go to tell when she will give birth." D. "She is doing well and is in the second stage; it could be anytime now."
A. "She is in active labor; she is progressing at this point and we will keep you posted." (At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.)
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? A. Bloody fluid B. Clear to straw-colored fluid C. Greenish fluid D. Cloudy white fluid
B. Clear to straw-colored fluid (The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.)
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? A. Have the client lightly push to meet the need. B. Have the client pant and blow through the contraction. C. Have the client divert the energy to squeezing a hand. D. Assist the client to a Fowler position.
B. Have the client pant and blow through the contraction. (The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.)
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? A. The contraction pains are 2 minutes apart and 1 minute in duration. B. The client reports back pain, and the cervix is effacing and dilating. C. The contraction pains have been present for 5 hours, and the patterns are regular. D. After walking for an hour, the contractions have not fully subsided.
B. The client reports back pain, and the cervix is effacing and dilating. (True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.)
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? A. Urinalysis B. Vaginal examination C. Leopold maneuver D. Nonstress test
B. Vaginal examination (A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.)
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.)
A nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information? A. "False labor contractions are regular." B. "False labor contractions intensify with walking." C. "False labor contractions usually occur in the abdomen." D. "False labor contractions move from the back to the front of the abdomen."
C. "False labor contractions usually occur in the abdomen." (False labor contractions are usually felt in the abdomen, are irregular, and are typically relieved by walking. True labor contractions move from the back to the front of the abdomen, are regular, and aren't relieved by walking.)
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? A. Risk factors B. Maternal status C. Fetal status D. Maternal obstetrical history
C. Fetal status (The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.)
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? A. 5.0 B. 5.5 C. 6.0 D. 6.5
D. 6.5 (Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.)
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!"? A. Time the contractions. B. Auscultate the fetal heart tones. C. Contact the primary care provider. D. Inspect the perineum.
D. Inspect the perineum. (The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.)
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. (An acceptable method for monitoring fetal heart rate (FHR) in a low-risk pregnancy is to use intermittent auscultation (IA). The most common practice is to place the woman on an external fetal monitor for 20 minutes to get a baseline evaluation of the FHR. If the pattern is reassuring, then a fetoscope, handheld Doppler device, or the external fetal monitor is used to monitor the FHR at intermittent intervals. The nurse should never threaten the client or make her feel guilty about not using the equipment due to any reason, including lack of staff or claiming she is endangering her baby by not using it. The order should already be written to allow the client the option of not using the monitor based on certain parameters of the fetal monitor reading.)
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? A. Reassuring; it is associated with normal acid-base balance. B. Worrisome; it may be associated with metabolic acidosis. C. Critical; it represents metabolic acidosis. D. Damaging; it is frequently associated with fetal neurological damage.
A. Reassuring; it is associated with normal acid-base balance. (The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.)
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A. "The warmth and buoyancy of the water has a nice relaxing effect." B. "I can stay in the bath for as long as I feel comfortable." C. "My cervix should be dilated more than 5 cm before I try using this method." D. "The temperature of the water should be at least 105℉ (40.5℃)."
D. "The temperature of the water should be at least 105℉ (40.5℃)." (Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.)
A client arrives at the birthing suite and tells the nurse that she believes she is in labor. Which assessments should the nurse prioritize at this time? Select all that apply. A. birth imminence B. fetal status C. risk factors D. labor preferences E. maternal status F. birth preferences
A. birth imminence B. fetal status C. risk factors E. maternal status (A woman may present to the birthing suite at any phase of labor. Therefore, it is important that the nurse immediately assesses for birth imminence, fetal status, risk factors, and maternal status. If birth is not imminent and the fetal and maternal conditions are stable, then the nurse should perform additional assessments including the full admission health history, a complete maternal physical assessment, the status of labor, and labor and birth preferences.)
A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? A. tight membranous attachments B. poorly ossified bones of the cranial vault C. rigid bones at the base of the skull D. well-ossified bones of the face
B. poorly ossified bones of the cranial vault (Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely (not tightly) bound to the cranial vault, which allows for molding of the fetal skull.)
Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide? A. "You need to get up and walk around a bit so that your bladder can get filled more fully," B. "Even though you are sweating, you still need to urinate at least every hour." C. "It is important to try to urinate every 2 hours because you might not feel the urge." D. "You need to give a urine specimen each time you urinate so we can check for infection."
C. "It is important to try to urinate every 2 hours because you might not feel the urge." (During labor, pressure from the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Therefore, it is important to have the pregnant client void approximately every 2 hours during labor to avoid overfilling, because overfilling can decrease postpartum bladder tone. Bladder filling is not affected, and there is no need to give a urine specimen with each voiding. Insensible fluid loss does occur with sweating, but is not associated with the need for voiding every 2 hours.)
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? A. The client is fully effaced. B. The fetus is floating high in the pelvis. C. The fetus is in the true pelvis and engaged. D. The fetus has descended down the birth canal.
C. The fetus is in the true pelvis and engaged. (When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.)
Which nursing action has a negative effect on fetal descent? A. laying the client on the left side B. using a tap water enema C. administering opioid pain medication D. walking the client in the hall
C. administering opioid pain medication (Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.)
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? A. Alert the team that internal fetal monitoring may be needed. D. Palpate the area just above the symphysis pubis. C. Institute effleurage and apply pressure to the client's lower back during contractions. D. Encourage the client to push.
D. Palpate the area just above the symphysis pubis. (Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.)