OB EAQ
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question?
Accompanied by progressive cervical dilation Progressive cervical dilation is the only positive sign of true labor; the cervix dilates in response to regular, coordinated uterine contractions. The contractions of true labor increase in length and intensity. A continuous contraction may have an adverse effect on the fetus; immediate intervention is required. The membranes may rupture before contractions begin; more frequently they rupture after true labor is established.
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event?
An acceleration An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate.
While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next?
Assess the fetal heart rate (FHR). The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, it is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.
During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?
Breathe into her cupped hands Dizziness and tingling of the hands are signs of respiratory alkalosis, most likely the result of hyperventilating. Breathing into cupped hands or a paper bag promotes the rebreathing of carbon dioxide. Panting during the next three contractions could cause the client to hyperventilate more. Holding her breath with the next contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or shallow breathing pattern could cause the client to hyperventilate more.
A client expresses a desire to breast-feed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breast-feed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request?
By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired
The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what?
Cause decreased placental perfusion In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.
A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean due to cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which nursing action should be taken after the initial physical assessment?
Determine the blood glucose level
A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement?
Encourage the family to bring in special foods preferred in their culture.
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what?
Estimate fetal age Measurement of the crown-rump length (CRL) is useful in approximating fetal age in the first trimester. Hydrocephalus cannot be detected during the first trimester. Ultrasonography is used to detect structural defects in the second trimester. It is too early in this pregnancy to determine fetal linear growth.
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram?
Increase fluid intake for 1 hour before the procedure. In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation.
The nurse assesses a fetal scalp monitoring site when admitting a newborn to the nursery. For which complication should the nurse monitor this newborn?
Infection The fetal monitoring site represents a break in the skin integrity of the scalp, which allows access by microorganisms. Because the fetal monitoring electrode is removed during birth, the infant no longer has the electrode attached to the scalp and there is no further risk for injury. A fetal scalp monitoring site does not interfere with feeding nor does it affect respirations.
A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What should the nurse do first?
Inspect her perineal area. Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?
Moderate serosa The uterus sloughs off the blood, tissue, and mucus of the endometrium post-delivery. This happens in three stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that's expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for the first three days following delivery. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts from day four through day 10, following delivery. Lochia alba is the final stage of lochia. Rather than blood, there will be a white or yellowish discharge that's generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around six weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than ten days.
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse's initial intervention be?
Remove secretions from the pharynx
While assessing a newborn the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. What complication does the nurse anticipate in light of these findings?
Respiratory distress syndrome The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant; however, there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?
Suctioning the mouth To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse's initial action does not clear the airway.
The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching?
The fetus gets nutrients from the amniotic fluid. The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.
Which information should the nurse include in the discharge teaching of a postpartum client?
The prenatal Kegel tightening exercises should be continued. Exercises may be resumed immediately and should be done for the rest of the life because they help strengthen the muscle needed for urinary continence and may inhance sexual intercourse.
The newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?
This reflexive response is an expected part of development
