NUR 328 Module 2

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? signs of infection fetal position FHR maternal comfort level

FHR Rationale: When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction? diastole decrement acme increment

acme Rationale: The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction.

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? increased agitation low Apgar decreased alertness increased crying

decreased alertness Rationale: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? decreased sedation increased feelings of control increased cervical dilation less anxiety

less anxiety Rationale: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid? hydroxyzine naloxone midazolam nalbuphine

naloxone Rationale: Naloxone is an opioid antagonist that can be given to reverse the effects of the central nervous system depression, including respiratory depression, caused by opioids. It is also used to reverse the side effects of neuraxial opioids. Nalbuphine is an opioid. Hydroxyzine is an ataractic. Midazolam is a benzodiazepine.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? shoulder breech vertex cephalic

shoulder Rationale: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.

On examination, the nurse determines the client is at 50% effacement. This means: the cervical canal is 2 cm long. the cervical canal is 1 cm long. the cervical canal is 2.5 cm long. the cervical canal is 1.5 cm long.

the cervical canal is 1 cm long. Rationale: Effacement refers to the length of the cervical canal. At 0%, the cervical canal is 2 cm long; at 50%, 1 cm long; and at 100%, the cervical canal is obliterated.

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH? 7.4 7 6.8 7.2

7.2 Rationale: Umbilical cord blood acid-base analysis is considered the most reliable indication of fetal oxygenation and acid-base condition at birth. The normal mean pH value range is 7.2 to 7.3.

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 every 20 minutes every 10 minutes every 5 minutes

every 15 minutes Rationale: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: lightening. placenta previa. start of labor. rupture of the membranes.

lightening Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor. It is a premonitory sign of labor and is not associated with rupture of membranes or placental previa.

While discussing labor with a client and her partner, the nurse is asked what the best position is for giving birth to the baby. The nurse provides them with information that indicates research has shown which position as the best? semi-Fowler's position lying on her back with feet in stirrups squatting position of comfort for the mother

position of comfort for the mother Rationale: Maternal positioning during labor has only recently been the subject of well-controlled research. Scientific evidence has shown that nonmoving, back-lying positions during labor are not healthy. Women should be encouraged to assume any position of comfort for them.

When assessing the effectiveness of the obstetrical regional analgesia received by a client, the nurse recognizes it is successful by the complete loss of pain sensation at which level of the spinal cord? below T6 level below T7 level below T5 level below T8 level

below T8 level Rationale: Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord.

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is: 1 cm below the pubic bone. 1 cm below the ischial spines. 1 cm above the ischial spines. 1 cm above the pubic bone.

1 cm above the ischial spines Rationale: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and referred to as a minus or plus, depending on its location above or below the ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spine, it is recorded as plus stations. Therefore this fetus is 1 cm above the ischial spines.

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location? 2 cm above the umbilicus at the level of the umbilicus one fingerbreadth below the umbilicus between the umbilicus and symphysis pubis

at the level of the umbilicus Rationale: After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts, approximately 1 cm (or fingerbreadth) each day after birth.

After conducting a review class on the labor and birth process for a group of nurses working in the community clinic, the nurse determines that the teaching was successful when the group identifies which factors as affecting the labor process? Select all that apply. place powers passenger participation patience

powers, passenger, patience Rationale: There are "five Ps" that affect the labor process. They are passageway, passenger, powers, position, and psychological response. There are an additional five that can also have an effect on the labor process. They include philosophy, partners, patience, client preparation, and pain control.

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: frequency. duration. intensity. peak.

frequency Rationale: Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

A young couple are anxious for the birth of their first child. The nurse discusses the options, including elective induction of labor for nulliparas. The nurse determines that additional teaching is necessary when the couple identifies which condition as being associated with this procedure? increased rates of cesarean sections postpartum hemorrhage neonatal resuscitation shorter hospitalizations

shorter hospitalizations Rationale: Elective induction of labor can lead to birth of an infant too early, a long labor, exposure to a high-alert medication with its potential side effects, unnecessary cesarean birth, and maternal and neonatal morbidity. Elective induction has a cascade of related interventions, such as an intravenous line, continuous electronic fetal monitoring, confinement to bed, amniotomy, pharmacologic labor-stimulating agents, parental pain medications, and regional anesthesia, each with its own set of potential complications and risks. These risks apply to all women having the procedure; however, for nulliparous women before 41 weeks of gestation with an unfavorable cervix, the main risk is cesarean birth after unsuccessful labor induction with the potential for maternal and neonatal morbidity and increased health care costs.

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply. "They typically last for about 3 minutes each time you have them." "They often spread downward before they go away." "They go away when you walk around or change position." "They usually feel like a tightening across the top of your uterus." "They usually happen in a regular pattern."

"They often spread downward before they go away.", "They go away when you walk around or change position.", "They usually feel like a tightening across the top of your uterus." Rationale: Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix. However, the contractions are irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes. As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity of these contractions increase. However, if the contractions last longer than 30 seconds and occur more often than four to six times an hour, the woman should be advised to contact her health care provider to be evaluated, especially if she is less than 39 weeks' pregnant.

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply. FHR baseline types of decelerations rhythm variability changes in baseline

types of decelerations, variability Rationale: Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations like electronic fetal monitoring (EFM) can.

A nurse is caring for a woman in labor and understands that as the fetus travels through the birth canal, the fetus makes positional changes that occur concurrently. Based on the nurse's conceptualization of their sequential occurrence, list the cardinal movements of labor in the correct order that the nurse would expect the fetus to move. All options must be used. internal rotation engagement flexion extension expulsion

1) engagement 2) flexion 3) internal rotation 4) extension 5) expulsion Rationale: The cardinal movements of labor describe the positional changes the fetus goes through as it travels through the passageway. They are deliberate, specific, and very precise that allow the smallest diameter of the fetal head to pass through a corresponding diameter of the mother's pelvic structure. Although cardinal movements are conceptualized as separate and sequential, the movements are typically concurrent. They are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.

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? 5 6 6.5 5.5

6.5 Rationale: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? Assist with insertion of a central venous access device for administration. Give the medication orally every hour for the first 4 hours. Administer the medication piggybacked into a primary IV line using a pump. Give the medication as an intramuscular injection using the Z-track technique.

Administer the medication piggybacked into a primary IV line using a pump. Rationale: Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It not given orally, via IM injection, or through a central venous access device.

The nurse is teaching a class to a group of pregnant women in their second trimester. Which information about the effects of maternal position on labor will the nurse include? A kneeling position puts pressure on the vena cava. Being upright promotes a sense of control for the mother. Lying supine causes less abnormal fetal heart rate patterns. The lithotomy position allows gravity to move the fetus downward.

Being upright promotes a sense of control for the mother Rationale: Use of any upright or lateral position compared to supine or lithotomy positions may enhance a sense of control by the mother, contribute to fewer abnormal fetal heart rate patterns, and assist gravity to move the fetus downward. A kneeling position removes pressure on the maternal vena cava and helps rotate the fetus from a posterior position to an anterior one to facilitate birth.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? promoting the woman's feelings of control providing clear information about procedures encouraging the woman to use relaxation techniques allowing the woman time to be alone

allowing the woman time to be alone Rationale: Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? green malodorous cloudy clear

clear Rationale: Amniotic fluid should be clear when the membranes rupture. During an amniotomy, a disposable plastic hook (an amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "I will have a strong one and then the next one will be weaker." "I feel pressure in my vagina when I have the contraction." "The contractions lessen after I drink a large glass of water." "I feel the tightening primarily in the front of my belly."

"I feel pressure in my vagina when I have the contraction." Rationale: True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? "It thins to let your baby change positions during labor." "Your cervix thins so that your contractions can increase." "Cervical thinning is a sign that your are in true labor." "You need the cervix to thin so it can stretch more easily."

"You need the cervix to thin so it can stretch more easily." Rationale: The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used. +2 station -4 station 0 station -2 station +4 station

1) -4 station 2) -2 station 3) 0 station 4) +2 station 5) +4 station Rationale: Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner.

Arrange the answers into the correct order. Mouse users arrange by clicking and dragging each answer to the desired location. Keyboard users can arrange though drop down by selecting the right order. The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used. Determine position. Determine attitude. Determine presentation. Confirm presentation.

1) Determine presentation. 2) Determine position. 3) Confirm presentation. 4) Determine attitude. Rationale: Leopold's maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. With the woman in the supine position, perform the first maneuver to determine presentation. The second maneuver determines position. The third maneuver will confirm presentation. The fourth maneuver is performed to determine the attitude of the fetus.

The client wants to avoid an episiotomy. What other technique would the nurse suggest the client try? Massage the perineum daily during the last trimester. Apply warm compresses to the perineum. Practice Kegel exercises during pregnancy. Give birth to the infant while lying on her back.

Apply warm compresses to the perineum. Rationale: Apply warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent an episiotomy. Kegel exercises are for strengthening the pelvic muscles. Lying on the back puts added strain on the perineum, which may result in tearing and massaging the perineum during the last trimester, is not the optimum technique.

A nurse is monitoring a woman in labor. When interpreting the assessment findings, an increase in which finding would the nurse identify as a deviation from the expected body response? Heart rate Respiratory rate Blood glucose levels Blood pressure

Blood glucose levels Rationale: As the woman progresses through birth, numerous physiologic responses occur that assist her to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats per minute; cardiac output increasing by 12% to 31% during the first state and by 50% by the second stage; blood pressure increases by up to 35 mm Hg; and respiratory rate increases as more oxygen is consumed. However, basal metabolic rate increases and blood glucose levels decrease because of the stress of labor.

Assessment of a pregnant woman in labor reveals that the fetal attitude is normal. The nurse interprets this as indicating which information? Select all that apply. Chin is on the chest. Fetal back is straight. Thighs are extended. Legs are flexed at the knees. The fetus is in a transverse lie.

Chin is on the chest., Legs are flexed at the knees. Rationale: Fetal attitude refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another. The most common fetal attitude when labor begins is with all joints flexed—the fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The fetus is in a longitudinal lie.

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? Continuous support through the labor process helps decrease the need for pain medication. Lying on an ice pack can help decrease the need for pain medication. Sitting in a hot tub helps decrease the need for pain medication. A quick epidural can replace the need for pain medication.

Continuous support through the labor process helps decrease the need for pain medication. Rationale: Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication.

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 less than 5 beats per minute. FHR fluctuation range is undetectable. FHR fluctuates from 6 to 25 beats per minute. FHR fluctuates over 25 beats per minute.

FHR fluctuates from 6 to 25 beats per minute. Rationale: Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Instruct the woman to bend her knees and flex her hips. Ask the woman to hold her breath while assessing the FHR. Palpate the mother's radial pulse at the same time. Have the woman lie completely flat on her back while auscultating.

Palpate the mother's radial pulse at the same time. Rationale: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? Ensure care during labor includes immunizations. Encourage women with previous cesareans to always have a cesarean. Reduce the rate of cesarean births among low-risk women Ensure all couples receive preconceptional genetic counseling.

Reduce the rate of cesarean births among low-risk women Rationale: Healthy People 2030 includes one goal related to cesarean births in the United States, "MICH-2030-06 Reduce cesarean births among low-risk women with no prior births." Healthy People 2030 has two goals related to cesarean births in the United States. They are to reduce the rate of cesarean births among low-risk women and reduce the rate. Immunizations and genetic counseling are not associated with women in labor.

During the examination, the health care provider mentions the fetus has a good attitude. The nurse explains to the parents that this means: the posture of the fetus is with arms at its side and legs straight. the fetus is presenting head first. the fetus is cooperating with the labor. the posture of the fetus is with all joints flexed for birth.

The posture of the fetus is with all joints flexed for birth. Rationale: The attitude refers to the posturing of the joints, either flexion or extension, and the relationship of fetal parts to one another. The most common fetal attitude when labor begins is with all joints flexed. This normal fetal position is most favorable for vaginal birth, presenting the smallest fetal skull diameters to the pelvis.

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering? antibiotic ataractic antiretroviral benzodiazepine

antiretroviral Rationale: Women who are HIV-positive are given a combination of antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S. Public Health Service recommend that women who are infected with HIV and have plasma viral loads of more than 1,000 copies/mL be counseled regarding the benefits of elective cesarean birth. Antibiotics would not be used. Ataractics and benzodiazepines would be used for systemic analgesia.

When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanel (fontanelle). Which description would the nurse include? triangular shape approximately 2 to 3 cm in size located at the back of the fetal head closes 8 to 12 weeks after birth

approximately 2 to 3 cm in size Rationale: The anterior fontanel (fontanelle) measures about 2 to 3 cm in size, is diamond-shaped, and closes 12 to 18 months after birth. The posterior fontanelle is triangular and located at the back of the fetal head. The posterior fontanelle closes about 8 to 12 weeks after birth.

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

baseline FHR Rationale: The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: a congenital defect. prolonged labor. cranial bones overlapping at the suture lines. extreme pressure in the vaginal vault.

cranial bones overlapping at the suture lines Rationale: This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? crowning engagement restitution descent

crowning Rationale: Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? peak duration frequency intensity

duration Rationale: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.

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

effleurage Rationale: Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR by Doppler at which frequency? every 10 minutes every 20 minutes every 30 minutes every 15 minutes

every 15 minutes Rationale: It is recommended that the FHR be assessed during the second stage of labor every 5-15 minutes min by Doppler or continuously by EFM.

A nurse is reviewing the FHR and notes it to be in the range of 100 to 106 bpm over the past 10 minutes. Which conditions might the nurse suspect as the cause? Select all that apply. fetal hypoxia prematurity prolonged umbilical cord compression maternal fever effect of maternal analgesia

fetal hypoxia, prolonged umbilical cord compression, effect of maternal analgesia Rationale: Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10 minutes or longer. It can be the initial response of a healthy fetus to asphyxia. Causes of fetal bradycardia might include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block. Maternal fever and prematurity are associated causes of fetal tachycardia.

The nurse encourages a woman in labor to ambulate based on the understanding that ambulating does what? Select all that apply. helps the fetus line up with the angle of the pelvis. Enlists the aid of gravity to move the fetus Encourages rotation of the fetus Increases the urge to push during the second stage. Widens one side of the pelvis Enhances the effectiveness of contractions

helps the fetus line up with the angle of the pelvis., Enlists the aid of gravity to move the fetus, Encourages rotation of the fetus, Increases the urge to push during the second stage., Enhances the effectiveness of contractions Rationale: Walking, like standing, takes advantage of gravity, makes contractions more productive, helps to increase the urge to push in the second stage, helps the fetus line up with the angle of the maternal pelvis, and encourages rotation of the fetus. Lunging widens one side of the pelvis.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? increased risk of infection potential placenta previa potential rapid birth of fetus increased risk of breech presentation

increased risk of infection Rationale: After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

Massage is an effective nonpharmacologic technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism? distracting the person from the pain causing vasoconstriction preventing sensation from reaching the brain increasing the release of endorphins

increasing the release of endorphins Rationale: Massage works as a form of pain relief by increasing the production of endorphins in the body. Endorphins reduce the transmission of signals between nerve cells and thus lower the perception of pain. Controlled breathing helps to distract the person from pain. Attention focusing and imagery prevent the sensation of contraction pain from reaching the block the pain sensation from reaching brain. Cold causes vasoconstriction.

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks? cervical os ischial tuberosity ischial spine pubic symphysis

ischial spine Rationale: Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as zero station.

A new dad is alarmed at the shape of his newborn's head. Assessment reveals swelling at the area of the presenting part. The swelling crosses the suture lines. The nurse suspects which condition? closed anterior fontanelle cephalohematoma molding caput succedaneum

molding Rationale: The changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as molding. Along with molding, fluid can also collect in the scalp (caput succedaneum), or blood can collect beneath the scalp (cephalohematoma), further distorting the shape and appearance of the fetal head. Caput succedaneum can be described as edema of the scalp at the presenting part. This swelling crosses suture lines and disappears within 3 to 4 days. Cephalohematoma is a collection of blood between the periosteum and the bone that occurs several hours after birth. It does not cross suture lines and is generally reabsorbed over the next 6 to 8 weeks. The findings do not suggest a closed anterior fontanelle.

A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared? less likely to need analgesia less likely to need anesthesia need for someone to control the situation unlikely to require cesarean birth

need for someone to control the situation Rationale: Prenatal education teaches the woman about the birth experience and increases her sense of control. An increasing body of evidence indicates that the well-prepared woman, with good labor support, is less likely to need analgesia or anesthesia and is unlikely to require cesarean birth.

The client is requesting information on the various pain medication management techniques that are available so she can decide which option she would like to choose for her impending birth. While gathering together the information, the nurse would indicate which technique as becoming very popular and effective? spinal analgesia neuraxial analgesia/anesthesia epidural analgesia systemic analgesia

neuraxial analgesia/anesthesia Rationale: Neuraxial analgesia/anesthesia is the administration of analgesic or anesthetic agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. Neuraxial analgesia does not interfere with the progress or outcome of labor. This technique involving minimal motor blockade has become more popular. The most important complication associated with systemic analgesics is respiration depression. Systemic analgesia and regional analgesia/anesthesia have become less common due to their potential complications.

A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: lasting about 30 seconds. relieved by walking. occurring about every 5 minutes. occurring in the abdomen and groin.

occurring about every 5 minutes. Rationale: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the women evaluated, especially if she is less than 38 weeks pregnant.

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

prolonged decelerations Rationale: 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.

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply. recurrent late decelerations fetal tachycardia minimal variability sinusoidal pattern fetal bradycardia

recurrent late decelerations, sinusoidal pattern, fetal bradycardia Rationale: FHR patterns that are predictive of abnormal fetal acid-base status include fetal bradycardia, sinusoidal pattern, and recurrent late decelerations. Fetal tachycardia and minimal variability, although each needs evaluation and continued monitoring, are not predictive of abnormal fetal acid-base status.

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? oxytocin progesterone relaxin prolactin

relaxin Rationale: As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? the presenting fetal part not visible rupture of membranes cervical dilation of 1 cm insertion by any staff

rupture of membranes Rationale: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: the buttocks are presenting first with both legs extended up toward the face. one arm is presenting. one leg is presenting. the fetus is sitting cross-legged above the cervix.

the buttocks are presenting first with both legs extended up toward the face. Rationale: In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.