NURS 3 - Mod 4 Intrapartum (Maternity) EAQ's

Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. 1 An admission to the hospital at the start of labor 2 When accelerations of the fetal heart rate (FHR) are noted 3 On maternal perception of perineal pressure or the urge to bear down 4 When membranes rupture 5 When bright, red bleeding is observed

1 - An admission to the hospital at the start of labor 3 - On maternal perception of perineal pressure or the urge to bear down 4 - When membranes rupture Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM), a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

The nurse is caring for a pregnant patient. What interventions should the nurse follow to ensure proper hygiene in the patient? 1 Clean the perineum of the patient frequently. 2 Clean the patient's teeth with a warm wet cloth. 3 Offer a warm washcloth to the patient for a face wash. 4 Allow cool water to flow on the patient's back for 5 minutes.

1 - Clean the perineum of the patient frequently. The patient's perineum should be cleaned frequently to prevent the risk for infection. This helps maintain proper hygiene and provides comfort to the patient. The nurse can clean the patient's teeth with an ice-cold wet washcloth, which helps prevent a feeling of thirst and dryness of the mouth. Using a warm cloth may not be helpful. The patient is offered a cool cloth for wiping her face, which helps prevent diaphoresis. Warm water should be poured on the patient's back to provide relaxation and accelerate labor. Using a warm washcloth for a face wash and placing cool water on the patient's back will not help in providing comfort.

When managing the care of a patient in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. What do these measures include? 1 Encouraging the woman to try various upright positions, including squatting and standing 2 Telling the woman to start pushing as soon as her cervix is fully dilated 3 Continuing an epidural anesthetic so that pain is reduced and the woman can relax 4 Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

1 - Encouraging the woman to try various upright positions, including squatting and standing Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

After observing the fetal heart activity in the electronic fetal monitor, the nurse suspects that the patient's umbilical cord is compressed. What did the nurse observe on the monitor? 1 Fetal heart rate (FHR) variable decelerations 2 Increase in the FHR 3 Decrease in the FHR 4 Early decelerations

1 - Fetal heart rate (FHR) variable decelerations A compressed umbilical cord, which can be determined by variable decelerations in the FHR, is commonly observed at the time of labor. Variable decelerations are seen as W- or U-shaped waves on the monitor. Umbilical cord compression does not affect the heart rate. Early decelerations in the FHR are observed when the head of the fetus is compressed.

A nurse performing a vaginal examination finds that the laboring patient is 7 cm, 100% effaced, 0 station, and the fetal position is RSP. What is the nurse's priority action? 1 Notify the health care provider. 2 No action is necessary at this time. 3 Encourage the patient to ambulate. 4 Assist the patient in repositioning herself.

1 - Notify the health care provider. The nurse's priority action is to notify the health care provider. The acronym "RSP" stands for "right sacrum posterior," which means the fetus is on the right side of the maternal pelvis with a sacral presentation. A vaginal delivery of a fetus in a sacral presentation (breech presentation) must be avoided due to the potential of injury to the fetus during birth. This patient will require a cesarean section. Taking no action, encouraging the patient to ambulate, or assisting the patient to reposition herself will delay a safe delivery.

What interventions does the nurse perform for a laboring patient with hypotension and fetal bradycardia? Select all that apply. 1 Notify the primary health care provider or anesthesiologist. 2 Monitor the fetal heart rate (FHR) every 5 minutes. 3 Monitor maternal blood pressure every 10 minutes. 4 Administer oxygen using a nonrebreather face mask. 5 Position the patient in Sims' or modified Sims' position.

1 - Notify the primary health care provider or anesthesiologist. 2 - Monitor the fetal heart rate (FHR) every 5 minutes. 4 - Administer oxygen using a nonrebreather face mask. The nurse must immediately notify the primary health care provider, anesthesiologist, or nurse anesthetist. The nurse must administer oxygen by nonrebreather face mask at 10 to 12 L/min or as per health care facility's protocol. The FHR must be monitored every 5 minutes. The patient must be turned to lateral position or a pillow or wedge must be placed under a hip to displace the uterus. Sims' or modified Sims' position may be used when spinal anesthesia is administered. Maternal blood pressure must be monitored every 5 minutes.

Which pieces of information are important to obtain when assessing a patient admitted with ruptured membranes? Select all that apply. 1 Odor of fluid 2 Amount of fluid 3 Time of rupture 4 Color of amniotic fluid 5 Activity at time of rupture

1 - Odor of fluid 2 - Amount of fluid 3 - Time of rupture 4 - Color of amniotic fluid Important information to obtain from a patient admitted with ruptured membranes is the amount of fluid, time of rupture, odor of fluid, and color of fluid. This information is important in identifying potential maternal and fetal risk factors. Activity at time of rupture is not necessary.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are what? Select all that apply. 1 Passenger 2 Placenta 3 Passageway 4 Psychological response 5 Powers 6 Position

1 - Passenger 3 - Passageway 4 - Psychological response 5 - Powers 6 - Position At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychological response.

While assessing a pregnant patient, the nurse observes a sinusoidal heartbeat pattern on the electronic heart monitor. What should the nurse interpret about the fetus from this report? 1 Presence of fetal anemia 2 Mild hypoxemia 3 Metabolic acidemia 4 Potential for congenital anomalies

1 - Presence of fetal anemia A sinusoidal pattern of the fetal heart rate (FHR) is observed as a smooth wave-like pattern on the monitor. This indicates that the fetus has severe anemia. Minimal variability in the FHR indicates that the fetus may have mild hypoxemia and metabolic acidemia. Moderate variability in the FHR indicates that the fetus is at a risk of congenital anomalies.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.

1 - The fetal presenting part is 1 cm above the ischial spines. Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

Why does the labor nurse encourage open-glottis pushing during the second stage of labor? 1 To avoid fetal hypoxia 2 To increase maternal blood pressure 3 To promote the descent of the fetus 4 To improve the strength of the contraction

1 - To avoid fetal hypoxia The labor nurse encourages open-glottis pushing during the second stage of labor to avoid fetal hypoxia, which can occur with the use of the Valsalva maneuver during the second stage of labor. Open-glottis pushing does not significantly raise the maternal blood pressure enough to affect the blood flow to the fetus. The force of the maternal diaphragm and abdominal muscles promotes fetal descent in the second stage of labor. Open-glottis pushing does not affect uterine muscle strength.

With regard to systemic analgesics administered during labor, nurses should be aware of what? 1 Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. 2 Effects on the newborn can include significant neonatal respiratory depression. 3 Intramuscular (IM) administration is preferred over intravenous (IV) administration. 4 IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

2 - Effects on the newborn can include significant neonatal respiratory depression. Effects depend on the specific drug given, the dosage, and the timing. Effects on the newborn can include significant respiratory depression. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

Which test is performed to determine if membranes are ruptured? 1 Urine analysis 2 Fern test 3 Leopold maneuvers 4 Artificial rupture of membranes (AROM)

2 - Fern test In many instances, a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

The diagnostic test reports of a pregnant patient reveal a baseline fetal heart rate of 175 beats/min. What does this finding indicate to the nurse? 1 Presence of fetal ischemia 2 Fetal tachycardia 3 Fetal bradycardia 4 Hypotension in the fetus

2 - Fetal tachycardia The normal baseline fetal heart rate ranges from 110 to 160 beats/min. If the fetal heart rate is more than 160 beats/min, then tachycardia in the fetus is indicated. Ischemia is a condition in which there is a reduced blood supply to the fetal tissues. Baseline heart rate below 110 beats/min indicates bradycardia in fetus. Hypotension indicates a blood pressure level below 120/80 mm Hg, which is a life-threatening condition for the fetus.

Which pelvic shape is most conducive to vaginal labor and birth? 1 Android 2 Gynecoid 3 Platypelloid 4 Anthropoid

2 - Gynecoid The gynecoid pelvis is round and cylinder shaped, with a wide pubic arch. Prognosis for vaginal birth is good. Only 23% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The platypelloid pelvis is flat, wide, short, and oval. The anthropoid pelvis is a long, narrow oval with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape.

The primary health care provider (PHP) reports that the baby of a patient may have an injury resulting from shoulder dystocia during labor. What patient clinical condition should the nurse infer from the report? 1 Preterm labor 2 Postterm pregnancy 3 Secondary uterine inertia 4 Hypertonic uterine dysfunction

2 - Postterm pregnancy Shoulder dystocia is the fetal risk in pregnant women that is associated with an increase in birth weight (macrosomia) resulting from a prolonged pregnancy. In preterm labor the fetus may have reduced birth weight, which does not increase the risk of shoulder dystocia. Secondary uterine inertia is also called hypotonic uterine dysfunction. Hypotonic uterine dysfunction and hypertonic uterine dysfunction have no relation with delay in pregnancy and do not cause shoulder dystocia.

A full-term pregnant patient reports labor pain. What would be the nature of contractions if the patient has false labor? Select all that apply. 1 Do not stop with change in position 2 Stop with use of comfort measures 3 Stop when the patient starts walking 4 Felt in back and abdomen above navel 5 Become stronger and last longer over time

2 - Stop with use of comfort measures 3 - Stop when the patient starts walking 4 - Felt in back and abdomen above navel The nurse should be able to distinguish between false and true labor. In false labor, the contractions usually stop if the patient is placed in a comfortable position or if the patient walks. Unlike true labor, the contractions of false labor are felt above the navel. The contractions of true labor do not stop with a change in position, and they usually become stronger and last longer over time.

The ultrasound scanning reports of a pregnant patient confirmed the presence of a fetus in single footling breech position. Upon reviewing the medical records, the nurse finds that the patient has previously undergone uterine surgery. Which method should be planned for the safe birth of the infant? 1 Internal version 2 Vaginal delivery 3 Cesarean section 4 External cephalic version

3 - Cesarean section Because the fetus is present in a single footling breech and the mother has a history of uterine surgery, a cesarean section would be the safest method of delivery. This helps prevent fetal distress. The external cephalic version should not be performed in the patients who have undergone uterine surgery, because it may cause uterine injury. The internal version is usually performed for patients with multifetal gestation. This is usually preferred for the delivery of the second fetus and may also cause maternal and fetal injury. Vaginal delivery is not advisable in this type of fetal presentation, because it may result in a prolapsed umbilical cord.

Upon reviewing the laboratory reports, the nurse finds that the patient has meconium in the amniotic fluid. What would the nurse infer from this finding? 1 The patient has a stillbirth. 2 The patient has placental abruption. 3 The patient has prolonged pregnancy. 4 The patient has elevated uterine contractions (UCs).

3 - The patient has prolonged pregnancy. Meconium is the stool of the neonate, which is usually observed after the birth. When meconium is observed in amniotic fluid, it signifies that the patient has prolonged pregnancy. A stillbirth signifies the death of the fetus, which is not related to the presence of meconium in the amniotic fluid. Placental abruption causes early birth, whereas lowered estrogen levels cause prolonged birth. Elevated UCs is a sign of labor, which does not cause meconium in the amniotic fluid.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 - Third The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

The nurse finds that the umbilical cord in a pregnant patient who is in labor has prolapsed, following the rupture of membranes. Which positions are suitable for the patient to promote fetal perfusion? Select all that apply. 1 Lithotomy 2 Recumbent 3 Trendelenburg 4 Modified Sims' 5 Knee-chest position

3 - Trendelenburg 4 - Modified Sims' 5 - Knee-chest position If a prolapsed umbilical cord is not managed on time, it may result in fetal hypoxia and death. The prolapsed cord may get compressed by the presenting part of the fetus, blocking the blood supply to the fetus. The compression on the cord can be relieved by gravity facilitated by patient position. If the patient is placed in Trendelenburg, modified Sims', or knee-chest position, the presenting part shifts off the prolapsed cord. This helps to maintain the fetal perfusion. Recumbent and lithotomy positions are preferred for vaginal delivery but may not be helpful if the cord has prolapsed.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? 1 Encourage her to empty her bladder. 2 Decrease her intravenous (IV) rate to a keep vein-open rate. 3 Turn the woman to the left lateral position or place a pillow under her hip. 4 No action is necessary because a decrease in the woman's blood pressure is expected.

3 - Turn the woman to the left lateral position or place a pillow under her hip. Turning the woman to her left side is the best action to take in this situation because this will increase placental perfusion to the infant while waiting for the doctor's or nurse-midwife's instruction. Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

Which device can be used as a noninvasive way to assess the fetal heart rate (FHR) in a patient whose membranes are not ruptured? 1 Tocotransducer 2 Spiral electrode 3 Ultrasound transducer 4 Intrauterine pressure catheter (IUPC)

3 - Ultrasound transducer An ultrasound transducer is used to assess the FHR by an external mode of electronic fetal monitoring. It does not require membrane rupture and cervical dilation. A tocotransducer can be used to assess the uterine activity (UA) in a pregnant patient whose cervix is not sufficiently dilated, but it does not assess the FHR. Spiral electrode is used as an internal mode of electronic fetal monitoring to assess the FHR. It can be used only when the membranes are ruptured and the cervix is dilated during the intrapartum period. IUPC is used to assess uterine activity in internal mode. It can be used only when the membranes are ruptured and the cervix is dilated during the intrapartum period.

The charge nurse instructed a group of student nurses about the monitoring of uterine activity (UA) during labor. Which statement by the student nurse is accurate regarding the calculation of Montevideo units? 1 "They can be calculated using an ultrasound transducer machine." 2 "They can be calculated using a spiral electrode monitoring device." 3 "They can be calculated using a tocotransducer monitoring system." 4 "They can be calculated with an intrauterine pressure catheter (IUPC)."

4 - "They can be calculated with an intrauterine pressure catheter (IUPC)." Montevideo units can only be calculated using the internal monitoring of UA. An intrauterine pressure catheter (IUPC) monitors UA internally. Therefore Montevideo units can only be calculated using the IUPC. Spiral electrode monitoring is used for assessing the fetal heart rate (FHR), not UA internally. The tocotransducer monitoring system is used to monitor the UA externally. An ultrasound transducer is also used to monitor the FHR externally.

The nurse is assisting a pregnant patient who is in labor. The nurse finds that the umbilical cord is protruding out from the vagina. With a gloved hand, the nurse attempts to put the umbilical cord into the vagina. The nurse continues to monitor the fetal heart rate, administers oxygen therapy to the patient, and increases the drip rate of the intravenous (IV) fluid. Which nursing action can lead to fetal and maternal complications? 1 Increasing the drip rate of the IV fluid 2 Monitoring fetal heart rate continuously 3 Administering oxygen therapy to the patient 4 Attempting to place the umbilical cord back

4 - Attempting to place the umbilical cord back A prolapsed umbilical cord can compromise the fetal perfusion. Therefore the nurse should act quickly to prevent fetal complications. The nurse should not attempt to replace the umbilical cord, as the cord can get compressed by the presenting part of the fetus, which could result in fetal hypoxia and death. Fetal heart rate should be monitored continuously to determine fetal perfusion. Oxygen therapy should be administered to the patient to promote fetal oxygenation. The drip rate of the IV fluid should be increased to promote fetal perfusion.

A patient will be administered a pudendal nerve block late in the second stage of labor. What effect of the pudendal nerve block does the nurse expect in the patient? 1 An increase in fetal heart rate (FHR) 2 Patient feels an increase in the bearing-down reflex 3 Relief of pain from uterine contractions 4 Decrease in pain in the vagina and perineum

4 - Decrease in pain in the vagina and perineum A pudendal nerve block anesthetizes the pudendal nerves peripherally. It relieves pain in the lower vagina, vulva, and perineum. It does not relieve the pain from uterine contractions. The bearing-down reflex is lessened or lost completely. It tends to cause fewer fetal complications and does not affect the FHR.

The nurse is evaluating the fetal monitor tracing of a patient who is in active labor. Suddenly, the fetal heart rate (FHR) drops from its baseline of 125 beats/min down to 80 beats/min. The nurse repositions the mother, provides oxygen, increases intravenous (IV) fluid, and performs a vaginal examination. The cervix has not changed. A few minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take? 1 Notify nursery nurse of imminent birth. 2 Insert a Foley catheter. 3 Start oxytocin (Pitocin). 4 Notify the primary health care provider (HCP) immediately.

4 - Notify the primary health care provider (HCP) immediately. If the FHR does not resolve, the primary HCP should be notified immediately. Notifying the nursery nurse that birth is imminent is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean birth may be warranted. This requires the insertion of a Foley catheter; however, the HCP must make that determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued.

Which nursing action should be initiated first when there is evidence of prolapsed cord? 1 Notify the health care provider. 2 Apply a scalp electrode. 3 Prepare the woman for an emergency cesarean birth. 4 Reposition the woman with her hips higher than her head.

4 - Reposition the woman with her hips higher than her head. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. Applying a scalp electrode is not appropriate at this time. Preparing the woman for an emergency cesarean birth is not the first priority.

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? 1 The laceration also involves the anterior rectal wall. 2 The laceration continues through the anal sphincter muscle. 3 The laceration extends through muscles of the perineal body. 4 The laceration extends through the skin and structures superficial to muscles.

4 - The laceration extends through the skin and structures superficial to muscles. A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? 1 FHR does not change as a result of fetal activity. 2 Average baseline rate ranges between 100 and 140 beats/min. 3 Mild late deceleration patterns occur with some contractions. 4 Variability averages between 6 to 10 beats/min.

4 - Variability averages between 6 to 10 beats/min. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings.

3 - Change maternal position. The usual priority is as follows: (1) discontinue oxytocin if infusing; (2) change maternal position (side to side, knee chest); (3) administer oxygen at 8 to 10 L/min by nonrebreather face mask; (4) notify physician or nurse-midwife; (5) assist with vaginal or speculum examination to assess for cord prolapse; (6) assist with amnioinfusion if ordered; (7) assist with birth (vaginal-assisted or cesarean) if pattern cannot be corrected.

Of these options, which is the nurse's priority action when observing this fetal heart pattern? 1 Notify the health care provider. 2 Assist with vaginal examination to assess for cord prolapse. 3 Change maternal position. 4 Assist with amnioinfusion.

1 - To document the finding The fetal heart strip shows an early deceleration indicating expected head compression during contractions. Documenting this finding is appropriate. Positioning the woman on the left side, applying oxygen via a face mask, and notifying the health care provider are correct actions for a late deceleration.

When the nurse observes this fetal heart pattern, what is the most important nursing action? 1 To document the finding 2 To position mother on left side 3 To apply 10 L of oxygen via face mask 4 To notify the health care provider