ch.21
A pregnant woman gives birth to a term fetus who has died in utero. She requests time after the birth to hold her baby. What is the best response by the nurse?
"Hold your baby as long as you like. Please let me know what I can do to help you."
A client is 2 weeks past her due date, and her health provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply.
- A presenting part is engaged. - The cervix is ripe. -longitudinal line
A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time?
Offer to take pictures and footprints of the infant once it is delivered.
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?
erratic
The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which order should the nurse question with regard to titrating the infusion upward for adequate contractions?
Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min.
Before calling the primary care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?
Check for a full bladder.
A woman has been in labor for the past 8 hours and she has progressed to the second stage of labor. However, after 2 hours with no further descent the provider diagnoses an "arrested descent." The woman asks, "Why is this happening." Which response by the nurse is the best answer to this question?
More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal. .
A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is post-term and has oligohydramnios. What does this increase the risk of during birth?
cord compression
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
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate?
providing a comfortable environment with dim lighting
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
place a hand gently on the fetal head to guide birth.
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?
contractions most forceful in the middle of uterus rather than the fundus
Mrs. Carter is admitted to the labor and birth unit. The lab results of her cervical culture for group B streptococcal were positive. What priority intervention will be initiated?
Ampicillin or cefazolin intravenous is given before delivery.
The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize?
Decrease the oxytocin drip rate.
The fetus of a pregnant patient is in a breech presentation. Where will the nurse auscultate fetal heart sounds?
High in the abdomen
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?
Prepare the client for a cesarean birth.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression.
A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem?
Uterine contractions are weak and ineffective.
The nurse is assessing a patient in labor. On which complication of labor as identified within the 2020 National Health Goals will the nurse focus?
Uterine rupture
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?
amniotomy
As part of a review class for perinatal nurses, the nurse is explaining the laboratory and diagnostic tests that can be conducted to evaluate a woman's risk for preterm labor. The nurse determines that additional teaching is needed when the group identifies which test as being used?
blood chemistry levels
A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?
brachial plexus assessment
A multipara woman is fully dilated and effaced and has been pushing for over 2 hours. The student nurse observing asks the nurse "What is causing this to last so long." Which would be considered the most accurate response to this student nurse's question about prolonged deceleration?
fetal head is in an abnormal position
The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?
"No birth is ever really dry, because amniotic fluid continues to be manufactured."
The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?
Assess contractions by using external monitor.
