Chapter 10: Nursing Care during Labor and Birth

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:

blue. Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.

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 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.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

cervical dilation (dilatation) of 2 cm or more For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation (dilatation) of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement?

"Anxiety can speed up the labor process." Anxiety causes the release of catecholamines, which slow down the labor process. Current research demonstrates that continuous labor support by a caring nurse results in better birth outcomes. Nurses can provide supportive care during labor and can influence birth outcomes in a positive way.

A maternal health nurse is triaging a pregnant woman who reports vaginal bleeding. Which question made by the nurse best assesses the client's condition?

"How many times have you changed sanitary napkins?" If a woman reports vaginal bleeding, the best assessment question is one that determines the number of sanitary napkins soiled. This determines how heavy the flow is and should be the priority. The remaining questions may be asked by the nurse; however, these are not the best questions to assess the client's condition.

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on." The woman can be encouraged to sip fluid, ice chips, or suck on hard candy if she becomes thirsty or nauseated by labor. It also helps to supply extra fluid. Although many hospital protocols dictate that women who present in labor should not partake of oral nutrition, there is little evidence to support this restrictive practice. However, if women are kept NPO during labor, they can be administered anesthesia safely in an emergency.

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. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally?

Continuous internal monitoring of uterine contractions Since this client has had a cesarean section, it is helpful to monitor uterine contractions, not resting tone. The nurse would follow the intensity of the contractions to avoid uterine rupture from the previous birth. External monitoring and intermittent fetal heart rate auscultation are noninvasive and not as helpful determining uterine contraction intensity.

It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following?

Deep variable decelerations more than 60 bpm below the baseline with every contraction Repetitive variable decelerations with loss of variability, or ones that last longer than one minute, or dip deeper than 60 bpm below the baseline are nonreassuring.

The nurse is preparing to perform the Leopold maneuvers on a pregnant client. Which action occurs first?

Determine the presentation The first action of the Leopold maneuvers is to determine the presentation. Determining position and attitude occur after determining the presentation. Determining the fetal movements is not part of the Leopold maneuvers.

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first?

Feel for the fetal buttocks or head while palpating the abdomen. The first maneuver involves feeling for the buttocks and head at the uterine fundus. Next, the nurse palpates on the side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

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

Increase in bloody show The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur During the transition phase, contractions are strong and intense. At this point the client may feel out of control and unable to go on. There may be an increase in the bloody show as delivery approaches. The client feels a burning in the perineum and an urge to push. The client may be irritable and restless and may cry. Due to patterned breathing, the client may hyperventilate. It is during the active phase of labor that the client becomes introverted and quiet.

Which method does the nurse use to determine fetal presentation, position and attitude?

Utilize Leopold maneuvers Leopold maneuvers are a noninvasive method of assessing fetal presentation, position and attitude by placing hands on the maternal abdomen and locating fetal body parts. Ultrasounds are not done by nurses and not typically done at this stage of pregnancy. Assessing fetal kicks and a vaginal examination are not accurate.

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor?

every 15 to 30 minutes During the active phase of labor, FHR is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor. The woman's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after ruptured membranes. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active and transition phases. Contractions are assessed every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 15 minutes during transition.

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 Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?

moderate A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or intense contraction feels like the forehead.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

"The temperature of the water should be at least 105℉ (40.5℃)." Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data?

A urine dipstick test to check for protein Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first?

Assess if the bladder is distended The nurse must consider causes impeding fetal descent. A full bladder may slow fetal descent. Encourage the client to void at least every 2 hours. Assessment of the fetal heart rate, contraction strength, and psyche is important to note but is not directly related to impeding the fetal descent.

A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritize at this time?

Ensure cervix fully dilated Before the client begins pushing, the RN should confirm the client's cervix is fully dilated to avoid trauma to the maternal tissues. Evaluating the maternal vital signs and fetal heart status are also important but are not the priority when assessing if the woman is ready to push when the urge begins. The nurse should have already been monitoring the bladder and ensure the client has an empty or close to empty bladder. This can also be evaluated but is not the priority.

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. 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.

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 best position for all women during labor is on their side.

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

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

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

Vaginal examination A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.

The client reports having a rupture of membranes that occurred 24 hours ago. When assessing the client, which data is most pertinent? Select all that apply.

Your temperature is 38.3°C (101°F). I am having green-tinged fluid discharge. I am having contractions which are 5 minutes apart. The fetal monitor states that the fetal heart rate is 186 beats/min The most pertinent data relates to the current client and fetal symptoms. A temperature of 38.3°C (101°F) is elevated. Green-tinged fluid possibly is meconium-stained amniotic fluid, indicating fetal distress. Contractions 5 minutes apart indicate the progression of labor. The fetal heart rate is elevated. Tetanus immunization is not a consideration at this time. Social considerations are not the most pertinent information to report.

A client is now in the second stage of labor. While doing the assessment, which data should the nurse prioritize?

contraction pattern every 15 minutes Assess the contraction pattern at least every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity). Early decelerations are benign and deep tendon reflexes are not a priority at this time.

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back The nurse assessing the client should first determine the fetal back before placing the fetoscope on the client's abdomen. The fetal back is determined first because it is through the back that the heart signals are best transmitted. During labor, the fetal heart rate should be assessed to check for any variations indicating distress. Fetal heart rate is auscultated by placing a fetoscope on the client's abdomen in the area of the fetal back. Determining the fetal head, shoulders, and buttocks would be of no help in localizing the heart sounds.

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply.

frequency duration intensity When assessing a woman's contraction pattern, it is important to include frequency, duration, and intensity. Although knowing the status of the membranes and activity of the fetus are both important, they are not part of the contraction pattern.

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 Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.

The nurse is admitting a client who has just arrived stating she is in labor. Which fetal assessments will the nurse prioritize on the initial vaginal examination? (Select all that apply.)

presentation position attitude When doing an initial vaginal examination on a patient in labor, the examiner can confirm presentation, position, attitude, and fetal station or degree of descent. The sex cannot be determined at that time. The fetal heart rate will initially be assessed via an external method.

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?

scalp edema Neonatal scalp edema is common after the use of a vacuum extractor. The edema may last up to 7 days. Increased intracranial pressure is not common, and vaginal or cervical lacerations are problems that may affect the mother.

A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor?

second stage When a woman states "I feel a lot of pressure" or "I want to have a bowel movement", it is likely she is in the second stage of labor and the baby will be born soon.

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?

Notify the health care provider about possible meconium. Amniotic fluid should be clear when the membranes rupture. 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. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient?

latent phase Contractions during the latent phase of labor are typically 5 to 10 minutes apart and last 30 to 45 seconds. The cervix is dilated 1 to 3 cm, and effacement begins.

Which assessment findings indicate a distressed fetus? Select all that apply.

Absent accelerations Late deceleration patterns Persistent bradycardia The nurse evaluates the fetal monitor for normal patterns and/or signs of fetal distress. Absent accelerations, late deceleration patterns and persistent bradycardia indicate client hypoxia. A fetal heart rate baseline of 140 and moderate variability are normal signs.

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 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.

Which nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods. Throughout the labor process, the client is not to lay flat on her back due to supine hypotension. This places weight on the great vessels and decreases blood flow. It is acceptable to place a pillow or wedge under one hip, thus distributing the client's weight to one side. The client may do the other options at different points throughout the labor process.

When assessing a client in labor, the nurse observes that the fetal heart rate (FHR) gradually falls from 150 bpm to 132 bpm during the contraction and returns to baseline at the end of the contractions. The nurse interprets this finding as associated with which possible condition?

Fetal head compression The FHR pattern is reflective of early deceleration usually occurring due to vagal nerve stimulation from fetal head compression. Umbilical cord compression causes variable deceleration. Poor placental circulation and acute fetal hypoxia cause late deceleration.

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in?

Inform the RN that your client may have ruptured membranes It is beyond the scope of the LPN to assess if the client's membranes have ruptured and this should be reported immediately to the RN who will then conduct the pelvic exam. The LPN may assist with this examination which could include the fern test. Deep palpations and checking the EFM would not be diagnostic for determining the condition of the membranes.

Which action is a priority when caring for a woman during the fourth stage of labor?

assessing the uterine fundus During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply.

latent active transition The first stage of labor includes three phases: latent, active, and transition.

The nurse notes that the client has a moderate amount of bleeding after birth. Which instruction is anticipated to control bleeding?

Put the newborn to the breast to suck. Allowing the baby to suck on the breast stimulates oxytocin release which helps the uterus to contract and control bleeding. Having the client bear down encourages bleeding. Clotting factors are not given to the client as it could cause clot formation. Some bleeding (lochia rubra) is normal after birth; however, the bleeding is controlled.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?

between the umbilicus and the symphysis pubis The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?

placenta previa Vaginal examinations should never be done if the woman presents with bright red painless bleeding until placenta previa is ruled out. The other options would not be concerns at this time based on the findings.

Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect?

Does not hyperventilate Goal: The woman's breathing pattern is effective. Expected Outcomes: The woman uses accelerated breathing techniques during contractions, does not hyperventilate, uses pant-blow techniques to refrain from pushing despite pressure from the fetal head.

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 This client is considered a low-risk pregnancy but some monitoring is still needed. Thus, an acceptable method for monitoring fetal heart rate is intermittent fetal heart rate auscultation. The client is placed on an external fetal monitor for a 20-minute baseline and, if within normal limits, then is checked via a fetoscope or handheld Doppler at intermittent intervals. Continuous external monitoring may be initiated later in the labor process but is not identified from the history. Fetal scalp sampling gives evidence of the fetal status.

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding?

Kangaroo care If the woman permits it, place the newborn skin-to-skin against her body and place several blankets over them. This technique (called kangaroo care) keeps the infant warm and promotes bonding.

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

prolonged decelerations 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.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the woman to push when she has a strong desire to do so During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?

"Unfortunately, I'm going to have to stay quite still in bed while it is in place." With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?

Assess and reposition the woman. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate. When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

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

Complete hand hygiene 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.

A nursing instructor is conducting a session introducing a group of nursing students to the various pieces of equipment used for intermittent fetal monitoring. The instructor determines the session is successful after the students correctly choose which methods can be used? Select all that apply.

Doppler fetoscope external fetal monitor Intermittent fetal heart rate auscultation can use fetoscope, Doppler, or external fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions. The Leopold's maneuver is used to determine the position of the fetus so the nurse can locate the best location for listening to the fetal heart, however, the heart rate can not be determine via this method..

The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply.

Fetal heart rate 198 bpm Urine output: 20 ml/hr Assessment parameters of hemodynamic stability include heart rate, blood pressure within normal limits, urine output greater than 30 ml/hr, and continuous fetal heart rate monitoring with a rate between 120 and 160 bpm. In this situation, the client's low urine output and high fetal heart rate are signs of being hemodynamically unstable.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions. First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor?

Imminence of birth It is best for the nurse to obtain a full admission health history, a complete maternal physical assessment, the status of labor process and cultural preferences. However, if the client's labor has progressed, there may be little information documented before the client is sent to the delivery room. Much of the admission information is personal data and pregnancy history that the client would be able to report. The preparation using prenatal care/classes and the presence of a support person does not influence admission data.

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.

Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears. Consider what occurs in the latent (or early phase) of the first stage of labor, which are contractions and effacement. The nursing interventions that impact maternal and fetal injury include monitoring vital statistics, reporting temperature elevation over 38℃ (100.4℉), and answering questions and encouraging client verbalization of fears. The client is often excited and talkative. The client does not need to be on bed rest or positioned on the left side unless there is a complication.

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call?

Shoulder dystocia When the fetal head is delivered but the baby's chin is drawn back just inside the vagina, that is commonly referred to as the "turtle sign" or evidence of shoulder dystocia. A shoulder dystocia emergency is called to get additional providers and equipment to the delivery room immediately. There is no evidence of fetal macrosomia or cephalopelvic disproportion in this situation. A nuchal cord would be felt and resolved by the health care provider completing the delivery.

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. 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.

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?

The uterus contracts and squeezes the cord against the fetus. Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variability.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.

A patient arrives at the birthing suite and tells the nurse that she believes she is in labor. Which assessments should the nurse prioritize at this time? Select all that apply.

birth imminence fetal status risk factors maternal status A woman may present to the birthing suite at any phase of labor. Therefore, it is important that the nurse immediately assess for birth imminence, fetal status, risk factors, and maternal status. If birth is not imminent and the fetal and maternal conditions are stable, then the nurse should perform additional assessments including the full admission health history, a complete maternal physical assessment, the status of labor, and labor and birth preferences.

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 Recent research has revealed that vigorous pushing techniques that employ the Valsalva maneuver are associated with increased fatigue. LOC is not normally affected and it is normally impractical to monitor blood pressure while the client is pushing vigorously.

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds?

in the woman's lower abdominal quadrant The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate 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.

When the client in the transition phase of labor experiences dizziness and tingling in the fingers and around the mouth from hyperventilation, the client is anticipated to be in:

respiratory alkalosis. The client experiencing hyperventilation blows off CO2 and thus places herself in alkalosis. Because it occurs from the respiratory system, it is termed respiratory alkalosis. The other options are incorrect.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

respiratory depression Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs. The fetus is stimulated via an acoustic vibrator. From the stimulation, the fetal heart rate accelerates. If the acceleration occurs, fetal acidosis is not present. Fetal movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal.

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes The fetus is at highest risk for umbilical cord prolapse after the rupture of membranes. It is important to assess the fetal heart rate for one full minute. The other options are not as high of a risk.

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response?

A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. An acceptable method for monitoring FHR in a low-risk pregnancy is to use intermittent auscultation (IA). The most common practice is to place the woman on an external fetal monitor for 20 minutes to get a baseline evaluation of the FHR. If the pattern is reassuring, then a fetoscope, handheld Doppler device, or the external fetal monitor is used to monitor the FHR at intermittent intervals. The nurse should never threaten the client or make her feel guilty about not using the equipment due to any reason, including lack of staff or claiming she is endangering her baby by not using it. The order should already be written to allow the client the option of not using the monitor based on certain parameters of the fetal monitor reading.

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 The nurse is correct to place the tocodynamometer on the fundus with the sensor facing downward and then strap it securely to the abdomen.

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?

Continue to monitor the client and the FHR As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary.

Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner?

Instruct the client to blow through the lips like blowing out candles. To deliver the fetus in a controlled manner, the client expels the fetus without force, allowing the body to naturally birth the baby. To accomplish this, the nurse instructs the client to blow through the lips instead of holding the breath and bearing down. This adds force and pressure to the birth. Changing positions and limiting fluid does not impact the birth process. The client is typically supine or in the lithotomy positions for the birth.

The obstetric nurse is monitoring a client during the third stage of labor. What change in status should the nurse prioritize and report?

Sudden chest pain Monitor the woman for any sudden change in status. Complaints of shortness of breath, chest pain, or tachypnea may indicate the development of an amniotic fluid embolism. This complication does not normally cause bleeding, decreased LOC or decreased heart rate.

The nurse is analyzing the electronic fetal monitoring tracing. Which report to the registered nurse is most accurate?

The client is having late decelerations. The fetal heart monitor tracing notes late decelerations. These decelerations begin late in the contraction and recover after the contraction has ended.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

The client who is very restless and is moving around in the bed The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.

Which psychosocial state is anticipated when the client enters the active phase of labor?

The client will become more quiet and introverted. The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions. It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.

The nurse has been monitoring the progression of labor for a primipara. At which time is the nurse most correct to prepare for delivery?

When the fetus is crowning The nurse is most correct to identify that preparing for delivery occurs when the perineum is bulging or the fetus is crowning in the primipara. Once the nurse identifies that the fetus is in this location, the nurse will prepare for delivery. This may include breaking the bed to form the delivery area. There is no relation of when the health care provider arrives and the delivery of the fetus. Some clients only push a couple of times and the fetus is delivered, not allowing enough time for preparation. Full dilation (dilatation) is an indicator that the labor has progressed but not the best indicator that delivery is close and preparation is required.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.