OB Exam 1 PrepU
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is light abdominal massage used to displace pain." "Effleurage is the effect of a full bladder on fetal descent." "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening."
"Effleurage is light abdominal massage used to displace pain." Explanation: Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.
A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? "That's wonderful. Medication during labor is not good for the baby." "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." "I respect your preference, whether it is to have medication or not." "Let me get you something for relaxation if you don't want anything for pain."
"I respect your preference, whether it is to have medication or not." Explanation: Individualizing care to meet a woman's specific needs is a nursing responsibility.
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? "It distracts your brain from the sensations of pain." "It causes the release of endorphins." "It blocks the transmission of nerve messages of pain at the receptors." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."
"It distracts your brain from the sensations of pain." Explanation: Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.
The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate? "Please talk to your primary care provider first to ensure it is safe." "Personally, I would use them, but I cannot tell you to." "There is no scientific evidence they work. You will just complicate your situation more." "Why would you do something as stupid as that?"
"Please talk to your primary care provider first to ensure it is safe." Explanation: It is important that the primary care provider knows if and when the client is using herbal supplements to ensure there will be no danger to the woman or fetus. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus none can be recommended regarding their efficacy or safety. The statement about personal use is inappropriate because the nurse should not reveal personal information. Telling the client that the herbs will complicate the situation is inappropriate because the statement is judgmental and there is no information, whether positive or negative that the herbs can be harmful. The statement about doing something stupid is demeaning to the client.
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding? 0% effaced. 50% effaced. 75% effaced. 100% effaced.
50% effaced. Explanation: A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 0.5 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? If the woman has a full bladder, labor may be uncomfortable for her. If the woman's bladder is distended, it may rupture. A full bladder or rectum can impede fetal descent. A full rectum can cause diarrhea.
A full bladder or rectum can impede fetal descent. Explanation: Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.
A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? Administration of 500 mL of IV Ringer's lactate Administration of 1000 mL of IV glucose solution Move the woman into a supine position Administration of aspirin
Administration of 500 mL of IV Ringer's lactate Explanation: The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution, because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain a woman does not lie supine but remains on her side after an epidural block, to help prevent supine hypotension syndrome. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? Monitor vital signs. Assess the amount of cervical dilation (dilatation). Obtain urine specimen for urinalysis. Monitor hydration status.
Assess the amount of cervical dilation (dilatation). Explanation: If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation (dilatation). Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.
A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client? Convert the birthing room to birth readiness before full dilatation is obtained Prepare to administer oxytocin Prepare the client for cesarean birth Darken the room lights
Convert the birthing room to birth readiness before full dilatation is obtained Explanation: Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.
A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method? Counterirritation stimulation blocks pain from traveling to the spinal cord. Needles are inserted along meridians to release endorphins and control pain. A machine is used to measure the patient's ability to relax during contractions. Small injections of sterile saline reduce are used to reduce the amount of back pain.
Counterirritation stimulation blocks pain from traveling to the spinal cord. Explanation: Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors. Low-intensity electrical stimulation blocks the afferent fibers, preventing pain from traveling to the spinal cord synapses from the uterus. Needles being inserted along meridians to release endorphins explain acupuncture. A machine to measure the patient's ability to relax during contractions explains biofeedback. Small injections of saline to reduce back pain explain intracutaneous nerve stimulation.
A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? Determine if the client is in true or false labor. Ask if this is the client's first pregnancy. Notify the healthcare provider. Assess to see if the client has any drug allergies.
Determine if the client is in true or false labor. Explanation: When a nurse first comes in contact with a pregnant client, it is important to first ascertain whether the woman is in true or false labor. Information regarding the number of pregnancies or history of drug allergy is not important criteria for admitting the client. The health care provider should be notified once the nurse knows the client's current status.
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? Engagement of fetus Dilation (dilatation) of cervix Rupture of amniotic membranes Bloody show
Dilation (dilatation) of cervix Explanation: The best determination of effective contractions is dilation (dilatation) of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.
Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms? Efferent fibers are blocked by continuously applied high-intensity stimulation. Pain is prevented from traveling from the uterus to spinal cord synapses. Electrical impulses are created that interfere with nerve transmission. TENS reduces apprehension and thereby complements narcotic action.
Electrical impulses are created that interfere with nerve transmission. Explanation: TENS therapy is similar to the process of gate control theory, meaning it interferes with transmission.
As a woman enters the second stage of labor, which would the nurse expect to assess? feelings of being frightened by the change in contractions reports of feeling hungry and unsatisfied falling asleep from exhaustion expressions of satisfaction with her labor progress
feelings of being frightened by the change in contractions Explanation: The nature of contractions changes so drastically— the urge to push is very strong—that this can be frightening
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:
lightening. Explanation: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor. It is a premonitory sign of labor and is not associated with rupture of membranes or placental previa.
A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly? lower quadrant of the maternal abdomen at the level of the maternal umbilicus above the level of the maternal umbilicus just below the maternal umbilicus
lower quadrant of the maternal abdomen Explanation: In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.
A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? preterm labor normal labor dystocia precipitate labor
preterm labor Explanation: Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth.
A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? bronchodilators tocolytic therapy muscle relaxants anti-anxiety therapy
tocolytic therapy Explanation: Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity.
During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? The patient is not complaining of leg cramps. The patient is not requesting pain medication. The patient is focusing on a painting during contractions. The patient asks for a cold compress at the end of a contraction.
The patient is not requesting pain medication. Explanation: Touch and massage work to relieve pain by increasing the release of endorphins. Both techniques may also work because they serve as forms of distraction. Many women find massage helpful in the first and second stages of labor. The use of therapeutic touch and massage for the patient in labor is not used to reduce leg cramp. Focusing on a painting during contractions is a form of distraction. Asking for a cold compress at the end of a contraction is not directly related to the use of therapeutic touch and massage during labor.
A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? "Call us back when you start having contractions." "Come to the clinic or emergency department for an evaluation." "Drink 3 to 4 glasses of water and lie down." "Come in as soon as you feel the urge to push."
"Come to the clinic or emergency department for an evaluation." Explanation: When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.
The nurse provides education to a postterm pregnant client. information will the nurse include to assist in early identification of potential problems? "Increase your fluid intake to prevent dehydration." "Be sure to measure 24-hour urine output daily." "Continue to monitor fetal movements daily." "Monitor your bowel movements for constipation."
"Continue to monitor fetal movements daily." Explanation: The nurse will teach the postterm client to monitor fetal movements daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Fetal heart rate in relation to contractions The station in which the fetus is located Maternal heart rate and blood pressure Maternal request for pain medication
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.
A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor? Reticulocyte count Lecithin/sphingomyelin ratio Nitrazine test Test for antiphospholipids
Lecithin/sphingomyelin ratio Explanation: The lecithin/sphingomyelin (L/S) ratio of the amniotic fluid helps predict the fetal lung maturity in a client with PROM who goes into labor. A reticulocyte count is used for testing sickle cell anemia. The nitrazine test aids in the diagnosis of PROM and differentiates the amniotic fluid that leaks out after PROM from the normal vaginal secretion. It does not aid in determining fetal lung maturity. A test for antiphospholipids is done in diagnosing antiphospholipids syndrome, and does not aid in determining fetal lung maturity.
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? Long axis of fetus is at 60° to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is at 45° to that of client.
Long axis of fetus is perpendicular to that of client. Explanation: If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.
A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia? Maternal respirations decrease from 20 to 14 breaths/minute. Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Maternal pulse increases from 78 to 96 beats/minute. Maternal temperature increases from 99° F (37.2° C) to 100° F (37.8° C).
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Explanation: As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, decreased beat-to-beat variability, and fetal bradycardia. The respiratory rate, pulse rate, and temperature are within normal limits for a laboring client
A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient? Oxytocin therapy Fluid replacement Pain management Increasing activity
Oxytocin therapy Explanation: With a prolonged descent, intravenous oxytocin may be used to induce the uterus to contract effectively. Fluid replacement, pain management, and activity will not cause the fetus to descend quicker.
A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process? Patient requests pain medication throughout the labor process. Patient uses breathing techniques to control anxiety and pain during labor. Patient tolerates the use of sanitary napkins to absorb vaginal secretions during labor. Patient refuses complementary and alternative techniques to control pain during labor.
Patient uses breathing techniques to control anxiety and pain during labor. Explanation: An outcome that indicates that the patient has less anxiety during labor and delivery would be the use of breathing techniques to control anxiety and pain during labor. Requesting pain medication, using sanitary napkins, and refusing complementary and alternative pain management techniques are not appropriate outcomes for labor and delivery.
A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina? Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. Place the client in Trendelenburg position and gently attempt to reinsert the cord. Contact the health care provider and prepare the client for an emergent vaginal birth.
Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Explanation: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.
The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus? Shoulder dystocia Umbilical cord prolapse Nuchal cord Breech position
Shoulder dystocia Explanation: The "turtle sign" is the classic sign that alerts the practitioner to the probability of shoulder dystocia. The fetal head delivers, but then retracts similar to a turtle. The fetal head may wiggle from side to side and fail to rotate.
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? Apologize and tell her that the photos will be destroyed immediately. Console her with the fact that she has other children. Tell her that the hospital will keep the photos for her in case she changes her mind. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.
Tell her that the hospital will keep the photos for her in case she changes her mind. Explanation: Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? Increase the oxytocin. Turn off the oxytocin. Increase the methotrexate. Turn off the methotrexate.
Turn off the oxytocin. Explanation: Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? Use a birthing ball and find a position of comfort. Stay low on her back to ease the back pain. Use the Valsalva maneuver for effective pushing. Ask for privacy, and have just the partner present.
Use a birthing ball and find a position of comfort. Explanation: The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.
A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: normal. a possible infection. meconium passage. transient fetal hypoxia.
a possible infection. Explanation: Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. 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; however, it is considered a normal occurrence if the fetus is in a breech presentation.
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? application of vibroacoustic stimulation tactile stimulation administration of oxygen by mask fetal scalp stimulation
administration of oxygen by mask Explanation: The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? placental separation aspiration amniotic fluid embolism congestive heart failure
amniotic fluid embolism Explanation: With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? breast stimulation amniotomy laminaria prostaglandin
amniotomy Explanation: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? cervix dilates 1 cm per hour fetus descends 2 cm per hour fetus descends 1 cm per hour cervix dilates 2 cm per hour
cervix dilates 1 cm per hour Explanation: A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation (dilatation). If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.
A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next? suctioning of the mouth and nose clamping of the umbilical cord checking for the cord around the neck drying of the newborn
checking for the cord around the neck Explanation: Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. Then the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium. Finally, the umbilical cord is double-clamped and cut between the clamps. The newborn is placed under the radiant warmer, dried, assessed, wrapped in warm blankets, and placed on the woman's abdomen for warmth and closeness (kangaroo care).
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? diffuse abdominal cramping rupturing of fetal membranes start of regular contractions dilation (dilatation) of cervix diameter to 10 cm
dilation (dilatation) of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor
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? crowning effacement 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.
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: acupressure. patterned breathing. therapeutic touch. effleurage.
effleurage. Explanation: Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.
It is necessary for the mother to have a forceps delivery. To reduce complications from this procedure, the nurse should: empty the mother's bladder. provide pain medication. have anesthesia provider present. call the neonatologist.
empty the mother's bladder. Explanation: Forceps delivery may be outlet, low, or midforceps depending on the station of the fetus and the rotation of the fetal head. Client consent must be obtained and the maternal bladder must be emptied to reduce the chance of bladder injury and to increase the room for the fetus. The anesthesia provider and neonatologist would only be necessary if there was suspicion of complications to the mother and the fetus.
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? first degree second degree third degree fourth degree
fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage infection depression pulmonary emboli
infection Explanation: There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? effacement and dilation (dilatation) of the cervix shortening of the upper uterine segment reduction in length of the cervical canal restoration of blood flow to uterus and placenta
restoration of blood flow to uterus and placenta Explanation: The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation (dilatation) of the cervix are other processes that occur during uterine contractions.
