OB Chapter 15-18, 23-24 :)
Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide? "You need to give a urine specimen each time you urinate so we can check for infection." "You need to get up and walk around a bit so that your bladder can get filled more fully," "It is important to try to urinate every 2 hours because you might not feel the urge." "Even though you are sweating, you still need to urinate at least every hour."
"It is important to try to urinate every 2 hours because you might not feel the urge." Explanation: During labor, pressure from the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Therefore, it is important to have the pregnant client void approximately every 2 hours during labor to avoid overfilling, because overfilling can decrease postpartum bladder tone. Bladder filling is not affected, and there is no need to give a urine specimen with each voiding. Insensible fluid loss does occur with sweating, but is not associated with the need for voiding every 2 hours.
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? "My cervix should be dilated more than 5 cm before I try using this method." "The temperature of the water should be at least 105℉ (40.5℃)." "I can stay in the bath for as long as I feel comfortable." "The warmth and buoyancy of the water has a nice relaxing effect."
"The temperature of the water should be at least 105℉ (40.5℃)." Explanation: Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.
A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat? "You can have a protein supplement." "I can get you something soft and easy to digest, like pudding." "What would you like to eat?" "You could have some hard candy to suck on."
"You could have some hard candy to suck on." Explanation: The woman can be encouraged to sip fluid, ice chips, or suck on hard candy if she becomes thirsty or nauseated by labor. It also helps to supply extra fluid. Although many hospital protocols dictate that women who present in labor should not partake of oral nutrition, there is little evidence to support this restrictive practice. However, if women are kept NPO during labor, they can be administered anesthesia safely in an emergency.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? +4 -5 0 +1
+4 Explanation: As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions get closer together with activity. Braxton Hicks contractions cause "ripening" of the cervix.
Braxton Hicks contractions usually decrease in intensity with walking. Explanation: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? Notify the primary care provider. Change the position of the client. Administer oxygen. Increase her IV fluids.
Change the position of the client. Explanation: Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.
The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences? Pressure in the perineum Descent of fetus into birth canal Stretching of cervix Fear of pain during labor
Fear of pain during labor Explanation: Fear of pain during labor is a psychosocial factor. The stretching of the cervix, descent of the fetus into the birth canal, and pressure on the perineum are physical factors.
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? Possible maternal infection Green-colored fluid in the vagina Fetal heart rate Irregular contractions
Green-colored fluid in the vagina Explanation: Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.
A client in labor is receiving epidural analgesia for pain management. The client is about to receive an additional dose at a specific interval. Which assessment is critical for the nurse to complete before the dose is administered? Have the client repeat, "I can do it" three times. Test the client's grasp strength. Check the client's deep tendon reflexes. Ask the client to state their name once.
Have the client repeat, "I can do it" three times. Explanation: Each time, before an additional dose at a specified interval (top-up dose) is administered, the nurse will ask the client to say out loud a phrase such as "I can do it" three times. If the client is unable to do this, the nurse should question the dose; lack of fine motor coordination and slurred speech can indicate a slowly occurring toxic reaction. The other actions are not related to topping up an epidural dose.
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? Push with contractions and rest between them. Pant while pushing. Begin pushing as soon as the cervix has dilated to 8 cm. Hold the breath while pushing during contractions.
Push with contractions and rest between them. Explanation: Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? "The analgesia will block pain sensation and limit your ability to push." "The analgesia will limit your ability to be out of bed without assistance." "The analgesia will allow for a pain-free birth experience." "The analgesia will reduce the sensation of pain for a limited period of time."
The analgesia will reduce the sensation of pain for a limited period of time." Explanation: It is best to prepare the client for the role of analgesia in her labor experience. It is best to explain that analgesia will reduce, not block or eliminate, the pain sensation for a limited period of time depending upon the medication selected. Stating the inability to get out of bed does not answer the client's question about pain relief.
Which psychosocial state is anticipated when the client enters the active phase of labor? The client will become more quiet and introverted. The client will become angry and begin to scream. The client will become tired and want the process over. The client will become more talkative and excited about the birth
The client will become more quiet and introverted. Explanation: The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? The client is fully effaced. The fetus is in the true pelvis and engaged. The fetus is floating high in the pelvis. The fetus has descended down the birth canal.
The fetus is in the true pelvis and engaged. Explanation: When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? The client can be sent home. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client is in active labor.
The frequency of the contractions is every 5 minutes. Explanation: Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.
The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? Pain perception is decreased if anxiety is present. These methods are a technique to prevent the painful stimuli from entering the brain. The gating mechanism opens so all the stimuli pass through to the brain. The gating mechanism is located at the pain site.
These methods are a technique to prevent the painful stimuli from entering the brain. Explanation: Gate-control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. Gate control does not need to be applied directly to the site of the pain. Anxiety heightens the painful feelings. Gating blocks the flow of painful stimuli to the sensory centers in the brain.
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Leopold maneuver Nonstress test Vaginal examination Urinalysis
Vaginal examination Explanation: A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? leakage from the perineum when the client coughs a positive bacterial culture greenish fluid noted on the client's underwear a positive nitrazine test
a positive nitrazine test Explanation: A confirmation that the client has a rupture of membranes includes a positive nitrazine test. A positive test is when the nitrazine paper turns a dark blue indicating that the fluid is alkaline. Urine also leaks when a client coughs. Greenish fluid on the underwear is not confirmation of the rupture of membranes. A positive bacterial culture is not indicative of the rupture of membranes.
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? a urine culture to rule out a urinary tract infection an ultrasound to determine fetal age a urine dipstick test to check for protein a blood culture to note any infection of the blood
a urine dipstick test to check for protein Explanation: Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.
Immediately after birth, the nurse shows the mother a part of the skull appearing as a diamond-shaped area which closes by approximately 18 months after birth? The nurse refers to this area as which of the following? vertex anterior fontanel (fontanelle) brow occiput
anterior fontanel (fontanelle) Explanation: The anterior fontanel (fontanelle), or bregma, is the diamond-shaped area in the fetal skull which closes approximately 18 months after birth. Bregma or the anterior fontanel is formed by the enlargement of the intersection of the sutures. Vertex is the area of the skull that lies between the anterior and the posterior fontanel. Occiput involves the area of the occipital bone. Brow is the area of the fetal skull that lies between the anterior fontanel and the eye socket.
The nurse is assigned four clients in the labor and birthing unit. Which client does the nurse assess last during assessment rounds? client at 37 weeks' gestation who is having an irregular pattern of contractions client who is newly admitted experiencing contractions every 4 minutes client who is experiencing variable decelerations on the fetal monitor client at 34 weeks' gestation with a cervical dilation (dilatation) of 6 cm
client at 37 weeks' gestation who is having an irregular pattern of contractions Explanation: Braxton Hicks contractions, or false labor, are usually mild but can be so strong that a pregnant client mistakes them for true labor. The mark of Braxton Hicks contractions is that they are usually irregular and are painful but do not cause cervical dilation (dilatation). This client can be assessed last when doing assessment rounds and may be sent home following assessment and health care provider notification of findings. The clients in active labor with cervical dilation (dilatation) and frequent contraction intervals are a higher priority. The nurse assesses the fetal monitor strip of the client having variable decelerations to identify a frequency and pattern of decelerations.
The client is now in the active 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 the client's breathing pattern to be effective, what outcome does the nurse expect? does not hyperventilate uses accelerated breathing patterns continuously pants through each contraction as the client pushes refrains from using the pant-blow technique so the client does nolt push
does not hyperventilate Explanation: The nurse will expect the client's breathing pattern to be effective, which mean the client will accelerated breathing techniques during contractions, does not hyperventilate, and uses pant-blow techniques to refrain from pushing despite pressure from the fetal head.
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? intensity duration peak frequency
duration Explanation: 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.
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. legs are flexed at the knees chin is on the chest thighs are extended the fetus is in a transverse lie fetal back is straight
legs are flexed at the knees the fetus is in a transverse lie chin is on the chest 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.
A nurse is preparing an in-service program about labor and the hormones involved with the initiation of labor. Which information would the nurse include as believing to play a role in the onset of labor?
withdrawal of progesterone Explanation: The onset of labor is believed to be due to a number of factors involving hormones. The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins. The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions. Changes in the ratio of estrogen to progesterone occurs, increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long the client will be in labor? "Your partner is in the active phase of labor, and birth will be within 2 to 3 hours, though it might be sooner." "Your partner is in active labor; they are progressing at this point and we will keep you posted." "Your partner is still in early latent phase of labor; it is too early to estimate when they will give birth." "Your partner is doing well and is in the second stage of labor; birth could be anytime now."
"Your partner is in active labor; they are progressing at this point and we will keep you posted." Explanation: At 7 cm dilated, the client is considered in the active phase of labor. There is no science that can predict the length of labor. The client is progressing in labor, and it is best that the nurse not give the family a specific time frame.
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: 0 station. crowning. +2 station. -2 station.
-2 station. Explanation: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.
A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? Tell her that it is her decision, but that she will be placing herself and her baby at grave risk. A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. Explain that you will have to call the physician and get an order to leave the fetal monitor off.
A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Explanation: An acceptable method for monitoring fetal heart rate (FHR) in a low-risk pregnancy is to use intermittent auscultation (IA). The most common practice is to place the woman on an external fetal monitor for 20 minutes to get a baseline evaluation of the FHR. If the pattern is reassuring, then a fetoscope, handheld Doppler device, or the external fetal monitor is used to monitor the FHR at intermittent intervals. The nurse should never threaten the client or make her feel guilty about not using the equipment due to any reason, including lack of staff or claiming she is endangering her baby by not using it. The order should already be written to allow the client the option of not using the monitor based on certain parameters of the fetal monitor reading.
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? Clear to straw-colored fluid Cloudy white fluid Greenish fluid Bloody fluid
Clear to straw-colored fluid Explanation: The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.
In the labor and delivery unit, which is the best way to prevent the spread of infection? Complete hand hygiene Use sterile gloves Limit vaginal examinations Provide clean gloves in the room
Complete hand hygiene Explanation: Hand hygiene remains the best way to prevent the spread of infection. It is appropriate to use sterile gloves for invasive procedures and limit vaginal examinations as much as possible. Providing clean gloves is also important when there is exposure to blood and body secretions.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation? Administer oxygen after turning the client on the left side. Stay with the client while reporting the finding to the health care provider. Continue to monitor the fetal heart rate because this pattern is benign. Perform a vaginal examination to assess cervical dilation (dilatation) and effacement.
Continue to monitor the fetal heart rate because this pattern is benign. Explanation: Early decelerations are a benign finding and not indicative of fetal distress. They do not require intervention; therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal examination, report the finding to the health care provider, or administer oxygen at this time.
Which cardinal movement of delivery is the nurse correct to document by station? Descent Extension Flexion Internal rotation
Descent Explanation: Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.
A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in? Check electronic fetal monitoring (EFM) for late decelerations. Perform deep palpation of the client's abdomen. Inform the RN that your client may have ruptured membranes. Perform a fern test.
Inform the RN that your client may have ruptured membranes. Explanation: It is beyond the scope of the LPN to assess if the client's membranes have ruptured and this should be reported immediately to the RN who will then conduct the pelvic exam. The LPN may assist with this examination which could include the fern test. Deep palpations and checking the EFM would not be diagnostic for determining the condition of the membranes.
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Time the contractions. Contact the primary care provider. Auscultate the fetal heart tones. Inspect the perineum.
Inspect the perineum. Explanation: The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.
A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? Check the pH to ensure the fluid is amniotic fluid. Notify the health care provider about possible meconium. Prepare to administer an antibiotic. Check the maternal heart rate.
Notify the health care provider about possible meconium. Explanation: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.
The nurse is caring for a client in active labor who states, "I need to go to the bathroom to have a bowel movement, now." Which action should the nurse take first? Request the unlicensed assistance personnel help the client to the restroom. Obtain a bedpan and allow the client to stay in bed for the bowel movement. Position the client for and perform a cervical assessment. Inform to the client this is a normal feeling during active labor.
Position the client for and perform a cervical assessment. Explanation: The beginning of the urge to bear down is a feature associated with the progression of labor leading into birth. At this time, cervical dilation (dilatation) may be complete and the nurse needs to assess to determine if the client is ready to begin the birth process. The client may experience an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. However, this is not priority. If the client has not progressed in dilation, the nurse could then assist the client to attempt to have a bowel movement. The client should not be left alone in case the fetus descends quickly and birth needs to happen quickly. The nurse would determine if the client should go to the restroom or use a bedpan based on the cervical assessment.
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? The cervix is dilating The uterus is relaxing The perineum is relaxing The cervix is softening
The cervix is softening Explanation: The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply. The cervix dilates to 10 cm. Effacement is noted as 0%. The cervix softens. Round ligaments contract. Vaginal rugae stretch and smooth out.
The cervix softens. The cervix dilates to 10 cm. Vaginal rugae stretch and smooth out. Explanation: Changes in the female body occur to allow the passage of the fetus down the birth canal. Vaginal rugae stretch and smooth out allowing for the ability of the fetus to descend. The cervix thins to a maximum of 10 cm and the cervix softens, becoming more accepting of the transition through by the fetus. Full effacement is noted as 100%. Round ligaments stretch to accommodate the expanding uterus and frequently result in discomfort in the antepartum period.
Which client outcome during the active phase labor is best? The client will tolerate 8 oz (240 ml) of clear liquids. The client will state a pain level of 7 or less during contractions. The client will practice breathing techniques during contractions. The client will walk in the hall for 15 minutes every 2 hours.
The client will practice breathing techniques during contractions. Explanation: The nurse identifies a priority during the active phase of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level will be less than 7 in the active phase. Walking in the hall and tolerating liquids also depends on the client.
Which assessment finding is most important as labor progresses? The uterus relaxes completely between contractions. Labor is completed within 18 hours. The client is remaining in control of emotions. 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.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? Fourth Third Second First
Third Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic? This can lead to maternal hypertension. This may prolong labor and increase complications. This would cause fetal depression in utero. The effects would wear off before delivery.
This may prolong labor and increase complications. Explanation: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients? Strictly follow universal precautions. Replace soiled drapes and linen as needed. Thoroughly wash the hands before and after client contact. Clean the woman's perineum with a Betadine scrub.
Thoroughly wash the hands before and after client contact. Explanation: The most important infection control technique in any health care setting is thoroughly washing hands on a routine basis. Keeping the area clean is secondary but also important.
A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? To prevent supine hypotension syndrome To aid the woman as she pushes during labor To prevent the woman from falling out of bed To decrease the heart rate of the fetus
To prevent supine hypotension syndrome Explanation: The term "rhythm strip testing" means assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, help a woman into a semi-Fowler position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test. Placing her in this position does not decrease the heart rate of the fetus. It is not done to aid the woman as she pushes in labor, as she is not in labor yet. It is not done to prevent her from falling out of bed.
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 Explanation: 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.
Which action is a priority when caring for a client during the fourth stage of labor? encouraging the client to void assisting with perineal care assessing the uterine fundus offering fluids as indicated
assessing the uterine fundus Explanation: During the fourth stage of labor, a priority is to assess the client's fundus to identify the risk for postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.
The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare? occiput presentation using a PowerPoint presentation footling presentation drawing a hand-prepared diagram breech presentation using a picture cephalic presentation using preprinted materials in the client's language
cephalic presentation using preprinted materials in the client's language Explanation: The most common presentation type is the cephalic presentation, and it is most appropriate to highlight the information using preprinted materials in the client's language. Both portions of this answer are best. With pictures, the nurse can communicate on a common level and then the client has the opportunity to review as needed. The breech and occiput presentations are not the most common types of fetal presentation. The footling is not a type of fetal presentation.
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? fetal movement through the birth canal cervical dilation (dilatation) regular contractions placental separation
cervical dilation (dilatation) Explanation: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? regular contractions placental separation cervical dilation (dilatation) fetal movement through the birth canal
cervical dilation (dilatation) Explanation: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.
A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment? detection of herpes virus infection detection of anemia detection of a respiratory infection detection of rales
detection of herpes virus infection Explanation: Examine the outer and inner surfaces of her lips carefully to detect herpes lesions (pinpoint vesicles on an erythematous base). Report to her primary care provider if herpetic lesions are present anywhere because although oral lesions are invariably a type I herpes virus (common cold sores), type II (genital) herpes virus needs to be identified as this can be lethal to newborns; a woman primary health care provider may suggest the woman with oral herpes lesions take isolation precautions such as not kissing her newborn until the lesions crust. Be certain to palpate for enlargement of neck lymph nodes to detect the possibility of a respiratory infection. Inspect the mucous membrane of her mouth and the conjunctiva of her eyes for color to see if paleness suggests anemia. Auscultate the woman's lungs to be certain they are clear of rales.
Which intervention would be least effective in caring for a clinet who is in the active phase of labor? encouraging the client to ambulate providing one-to-one support having the client breathe with contractions urging the client to focus on one contraction at a time
encouraging the client to ambulate Explanation: Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, the client should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the client cope with the events of this phase, as well as help the client maintain a sense of control over the situation.
A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritized at this time? evaluate fetal heart monitor evaluate maternal vital signs ensure cervix fully dilated ensure empty urinary bladder
ensure cervix fully dilated Explanation: Before the client begins pushing, the RN should confirm the client's cervix is fully dilated to avoid trauma to the maternal tissues. Evaluating the maternal vital signs and fetal heart status are also important but are not the priority when assessing if the woman is ready to push when the urge begins. The nurse should have already been monitoring the bladder and ensure the client has an empty or close to empty bladder. This can also be evaluated but is not the priority.
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels release of endorphins in response to the uterine contractions blocking of nerve transmission via mechanical irritation of nerve fibers distraction of the brain cortex by other stimuli occuring in the body
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Explanation: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.
Assessment of a client in labor reveals cervical dilation (dilatation) of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: active phase of the first stage. latent phase of the first stage. early phase of the third stage. pelvic phase of the second stage.
latent phase of the first stage. Explanation: The latent phase of the first stage of labor involves cervical dilation (dilatation) of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the pregnant client. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? presentation position lie attitude
lie Explanation: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? significant head molding thick vernix single palmar crease absence of testicular rugae
significant head molding Explanation: Since this is the mother's first birth, the birth canal has never been stretched. The labor process may take longer and may be tighter leading to significant molding as the fetal body, particularly the head, molds to the mother's birth canal. Thick vernix and absence of testicular rugae are a characteristics of prematurity. Genetic conditions such as trisomy 13 have characteristics of a single palmar crease as one of the signs of the potential disorder.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? False pelvis Perineum Uterus Cervix
Cervix Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
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? 6.5 5.5 5.0 6.0
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 in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: 7.21. 7.15 or less. 7.25 or more. 7.20.
7.15 or less. Explanation: In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.
A client has just received combined spinal epidural. Which nursing assessment should be performed first? Assess for spontaneous rupture of membranes. Assess vital signs. Assess for fetal tachycardia. Assess pain level using a pain scale. Assess for progress in labor.
Assess vital signs. Explanation: The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?
Before reporting to the RN, determine the uterine contraction pattern. Explanation: The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.
Which documentation in the health record is most correct for the third stage of labor? Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. Begins with the time of placental delivery and ends 48 hours later. Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus.
Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. Explanation: The nurse is most correct to record the time of the third stage of labor as beginning with the delivery of the fetus and ending with the delivery of the placenta. This time period is generally 5-20 minutes from delivery of the fetus.
A gravida 2, para 2 recently gave birth to a healthy 3304 g (7 lb, 6 oz) female newborn. There were no complications during the birth, and the parent appears to be well. Which action will the nurse take to assess this client's psychologic state after the pregnancy? Explore potential strategies to minimize stress when returning home. Ask if the client had any depressive symptoms after giving birth the first time. Encourage the client to talk about the birthing experience with the nurse and others. Ask the client about family history related to mental illness.
Encourage the client to talk about the birthing experience with the nurse and others. Explanation: After the birth, the nurse will encourage the client to talk about and share the experience. This "debriefing time" can be an important way to help the client appreciate everything that happened and integrate the experience into their total life. There is no evidence that this client has postpartum depression. Specifically asking about depressive symptoms or family mental health issues, like they were currently present, is inappropriate. While stress is inevitable, assessment of the stress would come before developing potential strategies.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal request for pain medication Maternal heart rate and blood pressure The station in which the fetus is located Fetal heart rate in relation to contractions
Fetal heart rate in relation to contractions Explanation: The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
Which is the most important nursing assessment of the mother during the fourth stage of labor? Hemorrhage Heart rate The mother's psyche Blood pressure
Hemorrhage Explanation: During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.
The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? Midline but low on the abdomen On the uterine fundus At the level of the umbilicus On the right side of the abdomen
On the uterine fundus Explanation: The nurse is correct to place the tocodynamometer on the fundus with the sensor facing downward and then strap it securely to the abdomen.
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? ROA LOP ROP LOA
ROA Explanation: The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Occurs in an irregular pattern Radiates from the back to the front Lasts about 20 to 25 seconds Slows when the woman changes position
Radiates from the back to the front Explanation: Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.
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 client begins back labor The contractions vary in length and intensity 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.
Which nursing action has a negative effect on fetal descent? using a tap water enema walking the client in the hall administering opioid pain medication laying the client on the left side
administering opioid pain medication Explanation: Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.
A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: yellow. pink. olive green. blue.
blue. Explanation: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: internal rotation, flexion, descent, extension, external rotation, expulsion descent, flexion, external rotation, extension, internal rotation, expulsion descent, flexion, internal rotation, extension, external rotation, expulsion internal rotation, descent, extension, flexion, external rotation, expulsion
descent, flexion, internal rotation, extension, external rotation, expulsion Explanation: The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? effacement crowning dilation (dilatation) molding
effacement Explanation: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: right upper quadrant. left lower quadrant. right lower quadrant. left upper quadrant.
left lower quadrant. Explanation: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control? thiopental hydroxyzine hydrochloride secobarbital meperidine
meperidine Explanation: Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the opioid or reduce anxiety.
A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation? relation of the fetal presenting part to the maternal ischial spine relation of the different fetal body parts to one another relationship of the presenting part to the maternal pelvis part of the fetal body entering the maternal pelvis first
part of the fetal body entering the maternal pelvis first Explanation: The term presentation is the part of the fetal body that is entering the maternal pelvis first. The relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. The relation of the fetal presenting part to the maternal ischial spine is termed the station.
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 do nothing, this is benign palpate for bladder fullness reposition the client on either side
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 monitoring a client at 38 weeks' gestation who is bleeding. Which assessment finding(s) indicates to the nurse that the client is hemodynamically unstable? Select all that apply. pulse oximeter: 95% heart rate: 82 beats/min blood pressure: 120/78 mm Hg fetal heart rate: 198 beats/min urine output: 20 ml/hr
urine output: 20 ml/hr fetal heart rate: 198 beats/min Assessment parameters of hemodynamic stability include heart rate and blood pressure within normal limits, urine output greater than 30 ml/hr, and continuous fetal heart rate monitoring with a rate between 120 and 160 beats/min. In this situation, the client's low urine output and high fetal heart rate are signs of being hemodynamically unstable.
A client is in the third stage of labor. Which finding alerts the nurse that the placenta is separating? umbilical cord shortens uterus becomes globular fetal head at vaginal opening mucus plug is expelled
uterus becomes globular Explanation: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before the birth of the head. Expulsion of the mucus plug is a premonitory sign of labor.
A nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information? "False labor contractions move from the back to the front of the abdomen." "False labor contractions usually occur in the abdomen." "False labor contractions are regular." "False labor contractions intensify with walking."
"False labor contractions usually occur in the abdomen." Explanation: False labor contractions are usually felt in the abdomen, are irregular, and are typically relieved by walking. True labor contractions move from the back to the front of the abdomen, are regular, and aren't relieved by walking.
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." "You need the cervix to thin so it can stretch more easily." "Cervical thinning is a sign that you are in true labor."
"You need the cervix to thin so it can stretch more easily." Explanation: 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.
The nurse is reviewing a pregnant client's birth plan. The client asks the nurse about the use of opioids during the labor process. How will the nurse respond? "You will feel less pain during the contractions, but will still feel some of the pain." "You may require urinary catheterization during the laboring process." "Using an opioid during labor may cause the baby to have seizures immediately after birth." "Sometimes opioids cause high blood pressure so we closely monitor your blood pressure."
"You will feel less pain during the contractions, but will still feel some of the pain." Explanation: When used as pain control during the laboring process, opioids will reduce, but not eliminate, the pain of contractions. Hypertension is a concern during intubation when using general anesthesia, not opioids. Seizures are not a side effect of any pain control measure. Urinary catheterization may be needed with an epidural, but not with opioid administration.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Complete cervical dilation (dilatation) and time of fetal birth Time of mucus plug expulsion and full cervical dilation Admission time and time of fetal birth Effacement time and time when contractions are regular
Complete cervical dilation (dilatation) and time of fetal birth Explanation: The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? 10:05 a.m. 11:15 a.m. 11:30 a.m. 10:30 a.m.
10:30 a.m. Explanation: Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives opioids or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? 90 to 140 bpm 110 to 160 bpm 120 to 170 bpm 100 to 150 bpm
110 to 160 bpm Explanation: The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)? 12 to 14 weeks 14 to 18 weeks 4 to 6 weeks 8 to 12 weeks
8 to 12 weeks Explanation: The posterior fontanel (fontanelle) is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanel (fontanelle) normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.
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? Administer the medication piggybacked into a primary IV line using a pump. Give the medication as an intramuscular injection using the Z-track technique. Give the medication orally every hour for the first 4 hours. Assist with insertion of a central venous access device for administration.
Administer the medication piggybacked into a primary IV line using a pump. Explanation: 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 is not given orally, via IM injection, or through a central venous access device.
It is most likely that the practitioner would consider performing an amnioinfusion if the EFM tracing shows which of the following?
deep variable decelerations more than 60 bpm below the baseline with every contraction Explanation: Repetitive variable decelerations with loss of variability, or ones that last longer than one minute, or dip deeper than 60 bpm below the baseline are nonreassuring.
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? fetal presenting part extent of opening to its widest diameter degree of thinning passage of the mucous plug
degree of thinning Explanation: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
At which time interval will the nurse assess the fetal heart rate of pregnant clients who are in the early active phase of labor? every 45 to 60 minutes every 15 to 30 minutes every 10 to 15 minutes every 2 to 4 hours
every 15 to 30 minutes Explanation: During the active phase of labor, fetal heart rate (FHR) is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor. The client's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after the membranes have ruptured. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active phase. Contractions are assessed every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 10 to 15 minutes during the late active phase.
A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver? fetal attitude fetal presentation fetal position fetal flexion
fetal presentation Explanation: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? complete footling frank full
frank Explanation: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth? fetus in partial extension with brow presenting to birth canal head flexed forward so much that the chin touches the sternum fetus in complete extension with back arched chin in moderately flexed military position
head flexed forward so much that the chin touches the sternum Explanation: A fetus in good attitude is in complete flexion; the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. This usual "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. The other attitudes listed are not ideal, because larger diameters of the fetus' skull are presenting.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? increase even if relaxing and taking a shower subside when walking around and use the lateral position remain irregular with the same intensity cause discomfort over the top of uterus
increase even if relaxing and taking a shower Explanation: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? increased blood coagulation time decreased plasma fibrinogen levels increased blood glucose levels increased white blood cell count
increased white blood cell count Explanation: The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: instruct the client or her partner to perform light fingertip repetitive abdominal massage. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. lead the client through a series of visualizations to aid in relaxation.
instruct the client or her partner to perform light fingertip repetitive abdominal massage. Explanation: Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique.
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? stage three latent active stage two
latent Explanation: The client in labor undergoes numerous psychologic adaptations during labor. During the latent phase, the client is often talkative and happy, and yet anxious. During active phase, the client may show fear and anger. Both the latent and active phases occur during stage 1. During stages 2 and, the client may remain positive, but the work of labor is very intense.
A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? tight membranous attachments poorly ossified bones of the cranial vault rigid bones at the base of the skull well-ossified bones of the face
poorly ossified bones of the cranial vault Explanation: Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely (not tightly) bound to the cranial vault, which allows for molding of the fetal skull.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations accelerations prolonged decelerations early decelerations
prolonged decelerations Explanation: 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 client 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 in 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.
