Nursing Care During Labor Chapter 10
A patient 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. -birth imminence -fetal status risk factors -labor preferences -maternal status -birth preferences
birth imminence fetal status risk factors maternal status Explanation: A woman may present to the birthing suite at any phase of labor. Therefore, it is important that the nurse immediately assess 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 woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? -intact membranes -cervical dilation of 2 cm or more -floating presenting fetal part -a neonatologist to insert the electrode
cervical dilation of 2 cm or more Explanation: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? -encouraging the woman to push when she has a strong desire to do so -alleviating perineal discomfort with the application of ice packs -palpating the woman's fundus for position and firmness -completing the identification process of the newborn with the mother
encouraging the woman to push when she has a strong desire to do so Explanation: During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor
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: -respiratory alkalosis. -metabolic alkalosis. -respiratory acidosis. -metabolic acidosis.
respiratory alkalosis. Explanation: 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.
A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor? -first stage -second stage -third stage -fourth stage
second stage Explanation: When a woman states "I feel a lot of pressure" or "I want to have a bowel movement", it is likely she is in the second stage of labor and the baby will be born soon.
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? -boggy, soft uterus -uterus becoming discoid shaped -sudden gush of dark blood from the vagina -shortening of the umbilical cord
sudden gush of dark blood from the vagina Explanation: Signs that the placenta is separating including a firmly contracting uterus, a change in uterine shape from discoid to globular ovoid, a sudden gush of dark blood from the vaginal opening, and lengthening of the umbilical cord protruding from the vagina.
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? -5.0 -5.5 -6.0 -6.5
6.5 Explanation: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5
The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally? -Continuous internal monitoring of uterine contractions -Continuous external monitoring of uterine contractions -Intermittent monitoring of the uterine resting tone -Intermittent fetal heart rate auscultation
Continuous internal monitoring of uterine contractions Explanation: Since this client has had a cesarean section, it is helpful to monitor uterine contractions, not resting tone. The nurse would follow the intensity of the contractions to avoid uterine rupture from the previous birth. External monitoring and intermittent fetal heart rate auscultation are noninvasive and not as helpful determining uterine contraction intensity.
Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect? -Does not hyperventilate -Uses accelerated breathing patterns continuously -Refrains from using the pant-blow technique so she doesn't push -Pants through each contraction as she pushes
Does not hyperventilate Explanation: Goal: The woman's breathing pattern is effective. Expected Outcomes: The woman uses accelerated breathing techniques during contractions. does not hyperventilate. uses pant-blow techniques to refrain from pushing despite pressure from the fetal head.
At which time does the nurse anticipate that the woman will need the most pain relief measures? -In the latent phase of the first stage of labor -At the beginning of the second stage of labor -During the transition phase of the first stage of labor -In the active phase of the first stage of labor
In the active phase of the first stage of labor Explanation: Pain medication is given the most in the active phase of labor. Implementing general comfort measures with narcotic analgesia or epidural anesthesia is common. During the transition phase, the woman's contractions become intense and include an urge to push. A goal for this period is that the woman's pain will be manageable. Comfort measures are most important as narcotics are not given at this advanced stage. Luckily, this phase is typically the shortest. The latent phase is the early portion of labor. This is frequently completed at home with comfort measures provided by the support person. The second stage of labor begins with full dilation and ends with the birth.
The client may spend the latent phase of the first stage of labor at home unless which occurs? -The client passes the bloody show -The contractions vary in length and intensity -The client begins back labor -The client experiences a rupture of membranes
The client experiences a rupture of membranes Explanation: Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.
The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? -The client states that she is having heavy bleeding. -When ambulating the client to the bathroom, a gush of red blood was noted. -The client has saturated three sanitary napkins in the past 4 hours. -The client has lost 100cc of blood from what I approximate on her clothing.
The client has saturated three sanitary napkins in the past 4 hours. Explanation: The best way to determine and report the amount of bleeding is by the number of sanitary napkins which have been saturated. This provides a common and measurable way to determine the approximate amount of bleeding. Stating heavy bleeding or a gush of blood is subjective. Determining the amount of bleeding from assessing stained clothing is difficult.
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place? -The uterus relaxes between contractions. -The uterus contracts and squeezes the cord against the fetus. -prematurity -fetal sleep
The uterus contracts and squeezes the cord against the fetus. Explanation: Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variabilty.
Which assessment finding is most important as labor progresses? -The client is remaining in control of emotions. -Labor is completed within 18 hours. -The uterus relaxes completely between contractions. -The pulse and respirations rise with the work of labor.
The uterus relaxes completely between contractions. Explanation: It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.
Which method does the nurse use to determine fetal presentation, position and attitude? -Assess location of fetal kicks -View on an ultrasound -Utilize Leopold maneuvers -Complete a vaginal examination
Utilize Leopold maneuvers Explanation: 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 a vaginal examination are not accurate.
When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR? -over the uterine fundus where contractions are most intense -above the umbilicus toward the right side of the diaphragm -between the umbilicus and the symphysis pubis -between the xiphoid process and umbilicus
between the umbilicus and the symphysis pubis Explanation: The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. -narcotic medication to maternal client -fetal movement -fetal distress -utero-placental insufficiency -maternal fever
fetal movement fetal distress utero-placental insufficiency maternal fever Explanation: An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of utero-placental insufficiency. Narcotics would lead to fetal bradycardia.
A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply. -latent -pre-labor -active -transition -inactive
latent active transition Explanation: The first stage of labor includes three phases: latent, active, and transition.
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? -notify the health care provider -reposition the client on either side -palpate for bladder fullness -do nothing, this is benign
reposition the client on either side Explanation: 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.
The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring? -The client who is having back labor and desires to lay on her side -The client who is very restless and is moving around in the bed -The client who has had a previous cesarean section -The client who is having an uncomplicated labor
The client who is very restless and is moving around in the bed Explanation: The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.
