CH. 14 PREPU

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.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. Explanation: The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

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." 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's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?

"It relieves pressure on the fetal head." Explanation: An episiotomy widens the vaginal opening, decreasing pressure on the fetal head.

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

FHR Explanation: When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?

The urge to push occurs. Explanation: Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.

The pain of labor is influenced by many factors. What is one of these factors?

The woman is prepared for labor and birth. Explanation: The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

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

conscious relaxation distraction pain relief without special tools Explanation: Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools. The basic breathing patterns can be taught by the nurse and are easy to learn and simple to perform.

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 Explanation: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?

every 15 minutes Explanation: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

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. 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 woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"The injection is given in the space outside the spinal cord." Explanation: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data?

The client has saturated three sanitary napkins in the past 4 hours. Explanation: The best way to determine and report the amount of bleeding is by the number of sanitary napkins which have been saturated. This provides a common and measurable way to determine the approximate amount of bleeding. Stating heavy bleeding or a gush of blood is subjective. Determining the amount of bleeding from assessing stained clothing is difficult.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?

effleurage Explanation: Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute. Explanation: Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?

Massage the woman's back. Explanation: Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.

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." Explanation: Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.

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?

"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.

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries." Explanation: When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

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 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.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety. Explanation: Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

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:

7.15 or less. Explanation: In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

A client in labor has received a spinal epidural block. Which nursing intervention should the nurse prioritize after assessing maternal hypotension and changes in the fetal heart rate (FHR)?

Administer supplemental oxygen. Explanation: Complications of a spinal epidural block include maternal hypotension, which affects the FHR. Supplemental oxygen should be administered to keep oxygenation levels appropriate for the mother and the fetus. The client should be placed in a semi-Fowler's position. Stopping the IV fluid may cause dehydration, and other positions may not have a positive effect on the blood pressure. Raising not lowering the woman's legs would be appropriate.

A client in labor has requested the administration of narcotics 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. Explanation: The timing of administration of narcotics in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate. Explanation: After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

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.

The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?

Blue Explanation: If the fluid in the vaginal canal is amniotic fluid, the Nitrazine paper will turn a dark blue, the color of an alkaline fluid, and this is a positive Nitrazine test for rupture of membranes.

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

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 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 Explanation: The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize?

Help the client regain control of her breathing technique. Explanation: The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is not improvement, notify the RN. Putting the patient in the hands-and-knees position should be avoided until later in labor.

The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize?

Help the woman change positions. Explanation: Changing to a different position is a first intervention to determine if this will improve the oxygen to the fetus. It may not necessarily mean to elevate the left hip with a pillow. The client could try sitting up and dangling her feet. Supplemental oxygen should be maintained until the mother is stable. Placing the client on her side may increase the work of breathing. Pharmacologic interventions are premature. Lying on the side with the left hip on a pillow is often used to correct postural hypotension related to the vena cava being compressed by the pregnant uterus.

Which complication occurs as a result of ineffective breathing patterns?

Hyperventilation Explanation: Vigorous application of breathing techniques can lead to hyperventilation. If hyperventilation occurs, have the client breathe into cupped hands or a paper bag. Hyperventilation is directly related to the breathing pattern. The other options may occur for a variety of reasons during the labor process.

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 Explanation: Because the client had epidural anesthesia, cannot lift her legs, and has not been out of the bed since the epidural, she is at risk for injury. The nurse should take all measures to make her safe because walking may be difficult for her at first. There is not enough substantial evidence to support the other nursing diagnoses at this time.

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. Explanation: Pain sensations associated with labor originate from different places depending on the stage of labor. During the first stage of labor, the stretching required to efface and dilate the cervix stimulates pain receptors in the cervix and lower uterine segment.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

Encourage her through the contractions, explaining why she cannot receive any pain medication. Explanation: At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

How does a woman who feels in control of the situation during labor influence her pain?

Feelings of control are inversely related to the client's report of pain. Explanation: Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.

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. Explanation: The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.

The following are nursing measures commonly offered to women in labor. Which nursing intervention probably would be most effective in applying the gate-control theory for relief of labor pain?

Massage the woman's back. Explanation: Gate control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area.

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?

Placing a wedge under the hips Explanation: Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension. Rubbing the legs or massaging the back can relax the client between intense contractions but those actions do not prevent a complication. Providing a paper bag prevents hyperventilation typically caused by pattern breathing.

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?

Provide care under the supervision of an RN Explanation: The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status Explanation: Opioids like fentanyl have significant effects on the client's respiratory status. This is the priority assessment because the other parameters are affected to a lesser degree.

When developing a labor plan with the client, which outcome is the priority?

The client will direct her pain management techniques. Explanation: Clients who have their pain managed report higher satisfaction with the birth experience. By working with the nurse in determining the labor plan, the health care provider, nurse and the client can work together to obtain a plan to manage labor pain. This puts the client in control of her care. The client nor the nurse is able to determine if a vaginal birth is feasible. It is rarely realistic to have a pain-free labor. Some discomfort is felt sometime within the labor process. It is strongly encouraged to have attended prenatal classes but not the priority.

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?

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.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia 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. 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.

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. Explanation: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Explanation: Women identify being involved in their pain management and adequate control of their pain as important factors in their overall labor experience. Women often report that it is not the amount of pain they have during labor that contributes to a satisfactory birth experience but rather how their pain is managed.

Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? Select all that apply.

effleurage counterpressure Explanation: Effleurage, a form of touch that involves light circular fingertip movements on the abdomen, is a technique the client can use in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation. If the client is experiencing intense back labor, it is often helpful for the partner to give the client a massage over the lower back or to use the fists or palms of the hands to apply counterpressure.

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?

endorphins Explanation: The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?

every 30 minutes Explanation: When a pregnant client is in the active phase of labor, the nurse should monitor the vital signs every 30 minutes. The nurse should monitor the vital signs every 30 to 60 minutes if the client is in the latent phase of labor and every 15 to 30 minutes during the transition phase of labor. Temperature is usually monitored every 4 hours in the active phase of labor.

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 Explanation: Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through ultrasonography or abdominal palpation but is not indicative of fetal oxygenation.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?

general anesthesia Explanation: General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

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. 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 student nurse is preparing to assess the fetal heart rate (FHR). She 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. 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.

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

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 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.

spinal abnormality hypovolemia coagulation defects Explanation: The nurse should check for any abnormality of the spine, hypovolemia, or coagulation defects in the client. An epidural is contraindicated in women with these conditions. Varicose veins and skin rashes or bruises are not contraindications for an epidural block. They are contraindications for massage used for pain relief during labor.

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

the presentation, lie, and attitude of the fetus. Explanation: Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

uterine resting tone frequency of contractions intensity of contractions Explanation: The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.