Passpoint Intrapartum Period
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?
"What is your expected due date?"
A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene?
60-79 beats per minute
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
Document fetal well-being.
Which nursing action is required before a client in labor receives an epidural anesthetic?
Give a fluid bolus.
Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?
Place the client in the Trendelenburg position.
A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action?
Place the mother in a knee-to-chest position.
A nurse is evaluating a fetal monitor strip and finds the fetal heart rate accelerated 20 beats per minute for 15 seconds. What is the nurse's best action?
Reassure the client that all is well with the fetus.
A low-risk multigravid client is in active labor and has begun pushing. The fetal head is beginning to crown. What action should the nurse take to prevent perineal lacerations during birth?
Stretch the perineal tissues with sterile gloved fingers.
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed oxytocin intravenously after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered?
The cord lengthens outside the vagina.
The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?
a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy
The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which type of presentation?
frank breech
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?
left lateral
The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use?
light stroking of the skin surface
An assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor?
loss of control
Which statement describes the term fetal position?
relationship of the fetus's presenting part to the mother's pelvis
A 24-year-old primigravid client in active labor asks to use the jet hydrotherapy tub to aid in pain relief. Which condition would the nurse consider to be a contraindication for hydrotherapy?
ruptured membranes
To determine whether a primigravid client in labor with a fetus in the left occiput anterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination, the nurse should palpate which cranial sutures?
sagittal
A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to
the social worker on call.
A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?
time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)
A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse?
"Changes in your blood pressure can affect the fetus."
A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?
"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."
A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood?
"The anesthetic may cause a severe headache, which is treatable."
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first?
Change the client's position.
The health care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?
Contractions cease.
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?
Influence of the extended family
A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?
Notify the physician that the partner has been waiting to discuss the mother's condition.
A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine
atony.
What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?
beginning of one contraction to the beginning of the next contraction
A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important?
fetal heart rate
The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?
increase in the fetal heart rate and variability
The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2°F (38.4°C). Examination indicates that the client is leaking amniotic fluid. What is the nurse's priority concern based on these findings?
intrauterine infection
When the nurse is preparing the room for admission of a multigravida client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?
padding for the side rails
A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?
spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
transitional phase
Which fetal presentation is most favorable for birth?
vertex presentation
A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: Give a 4-g bolus over 15 minutes, then decrease the rate to 2g/hour. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringer's on hand. What is the rate the nurse will set the pump to deliver the 2g maintenance dose? Record your answer using a whole number.
40
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g per hour intravenous (IV) piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using one decimal place.
50
A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which would be a priority intervention by the nurse to establish whether the client can have an epidural?
Assess cervical dilation.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
A nurse notices repetitive late decelerations on the fetal heart monitor. What are the best initial actions by the nurse?
Reposition the client, apply oxygen, and increase IV fluids.
The nurse performs the initial assessment and reports the following findings to the health care professional: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage or phase of labor?
active
The nurse is managing the care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client?
anesthesia and pain level assessment every 30 minutes
A nulligravid client in active labor receives an epidural anesthetic. What should be the nurse's priority assessment?
blood pressure
A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse?
blood pressure of 146/90 mm Hg
A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate?
checking for the umbilical cord around the neonate's neck
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean birth?
client at 38 weeks' gestation with active herpes lesions
The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action?
closed glottis pushing
In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion?
fetal heart rate accelerations
A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for which condition?
hypotension
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
latent phase
The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain?
no pain
A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?
offering support by reviewing the short-pant form of breathing
A laboring client at 28 weeks gestation is in preterm labor. Her partner gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse?
"You and your partner have been through a lot with this pregnancy. Let's talk about this further."
The nurse is caring for a couple in the transition period of labor. The client's partner asks about helping with the client's comfort at this time. What is the nurse's best response?
"You can stay close and help her focus on her breathing."
The nurse is caring for a client in labor who has tested positive for gonorrhea. Which will the nurse include in the client's plan of care?
Administer erythromycin eye drops to the infant after birth.
The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?
Check the fetal heart rate for bradycardia.
The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care?
Position the client on her left side.
The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what action should the nurse take next?
Prepare an area to receive the neonate.
The nurse is caring for a client who is attempting a trial of labor (attempt a vaginal birth after cesarean). Contractions are 1.5 minutes apart with a duration 75 to 90 seconds. The client reports a "sharp, tearing" pain, and the electronic fetal monitor (EFM) is no longer recording contractions. What is the priority nursing action?
Prepare the client for an emergency cesarean birth.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?
Remain in a side-lying position with the head elevated.
A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations from 100 to 110 bpm. What should the nurse do next?
Reposition the client and continue to evaluate the fetal heart rate.
The primary health care provider prescribes whole blood replacement for a multigravid client with abruptio placentae. What should the nurse do first before administering the intravenous blood product?
Validate client information and the blood product with another nurse.
A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor?
cervical dilation and effacement
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?
chaplain, because his educational background includes strategies for handling grief
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?
hypotension
A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?
massaging the uterus
A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?
physician
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them?
the client's partner
A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?
the intact membranes
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client makes which statement?
"I can have an epidural as soon as I start contracting."
A client at 28 weeks' gestation in premature labor was placed on nifedipine. To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? Record your answer using military time.
2200
After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when they say they will need to do which action?
Hold their breath throughout the length of the contraction.
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, the amniotic membranes rupture spontaneously. The client's cervix is 5-cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is normal. What should the nurse do first?
Note the color, amount, and odor of the amniotic fluid.
The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean birth. The client tells the nurse that they have been taking gingko biloba to help manage blood sugar. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?
prolonged bleeding
A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?
Stop the magnesium sulfate infusion.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position?
posterior
The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary?
"I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long."
A client in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when they make which statement?
"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."
The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response?
"The fetal heart rate went up twice during the test, so your fetus is doing well."
A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor after a cesarean and possible vaginal birth. After several hours of active labor, the health care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement?
"The contractions don't seem as painful as before."
The end of the third stage of labor is marked by what event?
delivery of the placenta
The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" What action should the nurse take first?
Inspect the perineum.
A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. What action should the nurse take next?
Notify the HCP that the membranes are ruptured.
A pregnant client's labor is progressing, but the cervix is still only 5 cm dilated and 100% effaced. Although the client appears relaxed, they are aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner?
"Encourage your partner to rest between contractions."
A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. What does this color indicate?
Rh sensitization
A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time?
Ask the client what fluids she prefers to drink.
A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area?
contraction frequency and intensity
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored?
Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my partner? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply.
"Encourage your partner to rest in between contractions." "Continue to praise your partner and give her encouragement." "Stay by your partner's side. It is important that she knows you are there to support her."
During preparation for a parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions?
"True labor contractions are felt first in the lower back, then the abdomen."
Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider?
A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which action should the nurse perform first?
Assess for presence of a full bladder.
A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is:
Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.
The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do?
Continue to monitor the client and fetus.
The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" The client's last vaginal examination was 1 hour ago and showed the client was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?
Perform a vaginal examination to determine if the client is fully dilated.
The health care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction?
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.
A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client?
complexity of care requirements
A 30-year-old multigravid client pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when they say that an electronic monitor performs which function?
ensures a more comfortable atmosphere for the client and labor
