OB Ch 26 Labor and Delivery
contractions every 4 mins.
A woman who in is the mid-to active phase of labor will be expected to have:
Ensure that the HCP has sterile gloves.
The HCP informs the nurse that there is a prolapsed umbilical cord. What should the nurse do 1st?
The start of 1 contraction to the start of the next
To assess the frequency of regular labor contractions, what should the nurse record?
Leopold's maneuvers
To determine fetal lie, presentation, and position, the caregiver uses which assessment technique?
Bloody show
A 23 yo primigravida arrives @ the labor unit in early labor. Which assessment finding indicates that labor has begun?
Performing a nitrazine test
A woman tells the nurse she thinks her membranes have ruptured. What action by the nurse best validates rupture of the membranes?
Urinary frequency
About 2 wks before the due date, a nullipara pt reports that the "lightening" that was described in the prenatal classes has occurred. Which physical change is likely to occur b/c of the lightening?
Increased pulse rate
Which maternal cardiovascular finding is expected during labor?
labor. delivery. the postpartum period. fetal development.
A birth plan includes the discussion of possible options r/t:
Monitor FHR for distress.
A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take 1st?
1st stage, latent phase
A nurse in the labor and delivery unit is assisting w/ the care of a client in labor and applies an external fetal monitor and tocotranducer. The FHR is around 140/min. Contractions are occurring every 8 mins and 30-40 secs in duration. The RN performs a vaginal exam and finds the cervix is 2 cm dilated and 50% effaced, and the fetus is @ a -2 station. Which of the following stages and phases of labor is this client experiencing?
Maternal fever
A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
Call for assistance.
A nurse is assisting w/ the care of a client in active labor. When last examined 2 hrs ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was @ a -2 station. The client suddenly states her water broke. The monitor reveals a FHR of 80-85/min. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform 1st?
Encourage use of patterned breathing techniques. Administer opioid analgesic medication. Suggest application of cold.
A nurse is assisting w/ the care of a client who is @ 40 wks of gestation and experiencing contractions every 3-5 mins and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take?
Fetal engagement
A nurse is caring for a client who has been in labor for 12 hrs, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal exam to ensure which of the following prior to the performance of the amniotomy?
Assist the client into the left-lateral position.
A nurse is caring for a client who is in labor and is experiencing late decelerations in the FHR. Which of the following actions should the nurse take 1st?
"Auscultate the FHR immediately following rupture of membranes."
A nurse is discussing intermittent fetal heart monitoring w/ a newly licensed nurse. Which of the following statements should the nurse include?
External monitoring cannot measure intensity of contractions.
A nurse is reinforcing teaching about external monitoring w/ a client who was recently admitted for induction of labor. Which of the following info should the nurse include?
"It can detect abnormal fetal heart tones early." "It allows for accurate readings despite maternal movement." "It can measure uterine contraction intensity."
A nurse is reinforcing teaching w/ a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include?
"Your cervix must be 2-3 cm dilated and your membranes ruptured before an internal monitor can be applied."
A pregnant woman is attending childbirth classes. She asks the nurse teaching the class when she would have an internal fetal monitor applied. What is the best nursing response?
Late decelerations
A woman has progressed through her labor without difficulty. However, the fetal heart rate has been decreasing w/ each contraction for the past 15 mins. The rate decreases from 150 to 125 bpm after the peak of the contraction and returns to 150 bpm 15 secs after the contraction is finished. What phenomena do the clinical manifestations most support?
Give simple breathing and relaxation instructions.
A woman pregnant for the 1st time is dilated 3 cm, w/ contractions every 5 mins. She is groaning and perspiring excessively and states that she did not attend childbirth classes. What is the most important nursing action?
Bearing-down reflex
As the woman's labor progresses, which assessment finding indicates that the 2nd stage of labor has begun?
fetal hemolytic disease.
Assessment of the amniotic fluid reveals yellow staining. The nurse is aware that this is associated with:
The nurse has just reviewed the fetal heart rate on an assigned laboring pt. What finding indicates the need to notify the charge nurse?
Late decelerations
Irritable and deeply focused
On exam, the pt is found to be 8 cm dilated w/ contractions every 3 mins that last for 70 secs. Which behavior is likely to occur in this transitional phase?
1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. External rotation and restitution 7. Expulsion
Steps in the mechanism of labor in the order in which they occur for vertex positions.
7
The baby is assessed after birth and the following are noted: hr 124/min, respiratory effort good, crying; some flexion of the extremities; grimacing; body pink, extremities bluish. Based on this info,what is the Apgar score?
The occiput is facing the right side and the front of the maternal pelvis.
The fetal position is ROA. Where is the fetal presenting part in relation to the maternal pelvis?
Inform her that delivery should occur within 24 hrs.
The nurse informs the mother that the results of the nitrazine test are blue-green, pH 6.5. What additional info should the nurse give to the mother?
Pt is not currently pregnant, but has a HX of pelvic fracture.
The nurse is assisting the HCP to measure the pelvis of several pts. Which pt is most likely to undergo pelvimetry?
Dry mouth Bradycardia Pruritus
The nurse is caring for a pt in labor who has had meperidine (Demerol) for pain relief. Which side effects are commonly associated w/ this drug?
To regain uterine muscle tone
The nurse is caring for a pt who has completed the 3rd stage of labor. What is the purpose and goal of massaging the fundus?
Squatting
The nurse is encouraging the mother to make frequent position changes during the 1st stage of labor. Which position promotes maternal cardiac output and placental perfusion?
Sodium citrate (Bicitra) Ranitidine (Zantac) Cimetidine (Tagamet) Famotidine (Pepcid)
The nurse is preparing a pt for a scheduled cesarean section. The nurse will administer meds to reduce gastric acidity. Which meds may be used?
Are reassuring
The nurse notes accelerations w/ fetal movement. The nurse correctly recognizes that heart accelerations most commonly:
Ambulation before membrane rupture
The nurse recognizes that which of the following is an acceptable practice in labor and delivery?
Separation of the placenta
The pt delivers an 8 lb, 1 oz boy. 10 mins later, there is a sudden gush of blood from her vagina. @ the same time, the woman's uterus becomes globular in shape and the umbilical cord lengthens. What do these findings most likely indicate?
A weakened abdominal wall increases the risk for a transverse lie.
The pt gives a HX of multiple pregnancies. What is the potential clinical significance for the fetus' attitude and lie within the womb?
Expect Braxton Hicks to increase in frequency as pregnancy progresses.
The pt in the 1st trimester reports an irregular tightening of the uterus and the HCP informs her that these are Braxton Hicks contractions. What additional info should the nurse give the pt?
stop the infusion.
The pt is receiving IV Pitocin for the stimulation of labor. The nurse notes that the fetal heart rate (FHR) is dropping below 100/min. The nurse should:
Monitor for postpartum hemorrhage
The woman received general anesthesia by inhalation. B/c the mother is @ this increased risk for uterine relaxation, which action will the nurse perform?
slow, deep chest or abdominal breathing.
When coaching the pt through the early or latent phase of labor, the nurse uses the breathing technique of:
Intrauterine infection
When planning care for a woman whose membranes have ruptured, the nurse recognizes that the woman's risk for what has increased?
Irritability, resistance to touch, withdrawal
When the woman enters the transition phase to active labor, which behaviors should the nurse expect to see?
Renewed energy for cooking and cleaning
Which behaviors/symptoms would be considered normal and expected a few days before onset of true labor?
Cephalopelvic disproportion is present. Mother has a cardiac condition. Prolapse of cord is present. Presentation is breech.
Which pts may be candidates for cesarean delivery?
Pt has high BP w/ symptoms of headache and dizziness. Pt has a HX of 1 stillbirth and 1 fetal demise. Pt has a HX of diabetes mellitus.
Which pts may be candidates for induction of labor?