PREPU Chapter 14: Nursing Management During Labor and Birth

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?

Intermittent fetal heart rate auscultation

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?

On the uterine fundus

A woman required an episiotomy and it was repaired by the birth attendant. Which instruction will the nurse give to the woman?

"The stitches used will absorb on their own."

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?

Check the chart for the last void.

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase

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?

meperidine

A client received IV nalbuphine in labor. The labor progressed rapidly and the nurse is preparing for the birth of the neonate less than 1 hour later. What medication will the nurse ensure is available immediately after birth of the neonate?

naloxone/narcan

The pregnant client is planning to hire a doula for support during labor. What statement by the client requires follow-up by the nurse?

My doula will help me with contractions so I will not need any pain relief in labor.

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 light abdominal massage used to displace pain."

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia."

Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide?

"It is important to try to urinate every 2 hours because you might not feel the urge."

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Administer oxygen by mask. Turn the client on her left side. Assess client for underlying causes.

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?

"You have no trouble walking around and using the bathroom after you receive the epidural." SUBMIT ANSWER

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used.

-4 station -2 station 0 station +2 station +4 station

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 seconds

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression.

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.

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

Client priorities and preferences are incorporated into the plan.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication?

Continuous support through the labor process helps decrease the need for pain medication.

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?

Dilation (dilatation) of cervix

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR

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?

Green-colored fluid in the vagina

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

Inability to push

Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply.

Increase in bloody show Irritability and restlessness may occur The client states an urge to push Hyperventilation may occur The client may begin to cry

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!"?

Inspect the perineum

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable.

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

Palpate the mother's radial pulse at the same time.

A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement?

Provide emotional and physical support.

The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time?

Risk for Injury

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the provider.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions.

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

Vaginal examination

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering?

antiretroviral-zidovudine

The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first?

assess BP

A pregnant client in labor receives a pudendal block for pain relief. Which action by the nurse would be appropriate after the block is given?

assess maternal blood pressure

Patterned breathing techniques used in labor provide which benefits? Select all that apply.

conscious relaxation distraction pain relief without special tools

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

determining the lie of the fetus determining the presentation of the fetus determining the position of the fetus

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

A client is ready to push. The nurse instructs her to push vigorously and grunt and breathe out during a pushing effort. What would be important to monitor on the client while she is pushing vigorously?

fatigue

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

headache following anesthesia

A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply.

hypovolemia spinal abnormality coagulation defects

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?

ischial spine

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

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

left lower quadrant.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?

less anxiety

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes?

provide supplemental oxygen

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?

rupture of membranes

The nurse is caring for a woman in early labor who is anxious and tense, therefore hindering her progression of early labor. What will the nurse prepare to administer?

secobarbital

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next.

A woman's perception of pain can differ according to all of the following except:

the presentation, lie, and attitude of the fetus.

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply.

types of decelerations variability