Chapter 14 Nursing management during labor and birth Intrapartum,

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? 1. Active phase 2. Latent phase 3. Descent phase 4. Transitional phase

4 RATIONALES: In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the cervix dilates from 5 to 7 cm, and moderate contractions progress to strong contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm, and contractions are short, irregular, and mild. No descent phase exists. (Fetal descent may begin several weeks before labor but usually doesn't occur until the second stage of labor.)

A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions? 1. By timing the period between one contraction and the beginning of the next contraction 2. By timing the period from the onset of uterine tightening to uterine relaxation 3. By timing the period from the increment (building-up) phase to the acme (peak) phase 4. By timing the period from the acme (peak) phase to the decrement (letting-down) phase

Answer: 2 RATIONALES: To determine the duration of contractions, the nurse should time the period from the onset of uterine tightening to uterine relaxation. Timing the period between one contraction and the beginning of the next contraction helps determine the frequency of contractions. Timing the period from the increment to the acme or from the acme to the decrement supplies only partial information about contractions.

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her care plan? 1. Carefully titrating the oxytocin based on her pattern of labor 2. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes 3. Allowing the client to ambulate as tolerated 4. Helping the client use breathing exercises to manage her contractions

Answer: 3 RATIONALES: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.

The nurse is assessing the fetal heart rate (FHR) of a client, who is at term, admitted to the labor and delivery area. Which of the following should the nurse identify as the normal range of the baseline FHR? 1. 60 to 80 beats/minute 2. 80 to 120 beats/minute 3. 120 to 160 beats/minute 4. 160 to 200 beats/minute

Answer: 3 RATIONALES: In a full-term fetus, the baseline FHR normally ranges from 120 to 160 beats/minute. FHR below 120 beats/minute reflects bradycardia; above 160 beats/minute, tachycardia.

The third stage of labor ends with which of the following? 1. The birth of the baby 2. When the client is fully dilated 3. After the delivery of the placenta 4. When the client is transferred to her postpartum bed

Answer: 3 RATIONALES: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the baby. The fourth stage of labor includes the first 4 hours after birth.

A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should the nurse anticipate for this client? 1. Mid forceps 2. Low forceps 3. Induction 4. Cesarean

Answer: 4 RATIONALES: For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.

What is the definition of Labor?

Contractions with cervical change.

After pitocin has been administered, how often should the fetal monitoring be checked? How often should vitals be taken? How often should temperature be checked?

FHR/FT : Q15min. VS : Q30min Temp. :Q4hrs (if fever Q1hr.)

Which medication is administered to reverse the depressant effects of opioids? a) Nalbuphine (Nubain) b) Butorphanol (Stadol) c) Naloxone (Narcan) d) Meperidine (Demerol)

Naloxone (Narcan) Correct Explanation: Naloxone (Narcan) is an opioid antagonist. Butorphanol (Stadol), nalbuphine (Nubain), and meperidine (Demerol) are opioids.

A woman arrives in labor and delivery, is panting and screaming "the baby is coming". What is the priority intervention by the nurse? a) Quickly move the woman to a labor bed, check the perineum b) Admit her to the unit and escort to a room c) Assess vital signs d) Ask medical and obstetrical history

Quickly move the woman to a labor bed, check the perineum Correct Explanation: The woman is showing signs of advanced labor, possibly in transition or stage two. She needs to be managed as an imminent birth and taken directly to a room for vaginal assessment. Vital signs, medical/obstetrical history, and her room assignment can be taken care of later in the process.

Sarah has just arrived at the hospital, in early labor, showing signs of extreme anxiety over the birth to come. Why is it so important that the nurse help Sarah relax? a) This is the time at which the nurse must establish that she is in control; she will be taking care of Sarah and Sarah needs to trust the nurse b) Sarah's anxiety can actually slow down the labor process and decrease the amount of oxygen reaching the uterus and the fetus c) Sarah needs to sleep now so that she can save her energy for the later stages of labor d) Sarah's anxiety will increase her blood pressure, increasing her risk with an epidural

Sarah's anxiety can actually slow down the labor process and decrease the amount of oxygen reaching the uterus and the fetus Correct Explanation: Anxiety out of control can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and have a negative impact on the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural. It is premature to be stern with the patient. While it is preferable that she save her energy, it is not damaging to her or to the fetus if she does not sleep.

If the monitor pattern of uteroplacental insufficiency were present, which of the following would you do first? a) Turn her or ask her to turn to her side. b) Ask her to pant with the next contraction. c) Administer oxygen at 3 to 4 L by nasal cannula. d) Help the woman to sit up in a semi-Fowler's position.

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

The pain of labor is influenced by many factors. What is one of these factors? a) Woman has a high threshold for pain b) Woman has a high tolerance for pain c) Woman has lots of visitors during labor d) Woman's preparation for labor and delivery

Woman's preparation for labor and delivery Correct 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.

Variable decellerations in fetal heart monitor indicates what?

Pressure on the cord causing circulation problems. • Prolapsed Cord • Fetus positioned on cord • Insufficient profusion to fetus

What are the 2 types of Episiotomies? What are there benefits?

1. Midline (Faster Healing, Less Muscle Damage, Risk of tearing anus) 2. Medial Lateral (Slow healing, More muscle repair, No risk of tearing Anus)

When a pregnant client arrives at the hospital and is taken to triage to determine what stage of labor she is in, the nurse gets a urine sample immediately, what is being tested for and what are the implications?

Protein : Hypertention Nitrates : Infection Ketones : Renal Problems and Glucose (Diabetic?)

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive assessment that uterine contractions are effective would be: a) Bloody show b) Dilatation of cervix c) Engagement of fetus d) Rupture of amniotic membranes

Dilatation of cervix Correct Explanation: The best determination of effective contractions is dilation of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.

A client is having contractions every 6-8 minutes apart lasting for 30 seconds and are mild in intensity. Her cervix is 2cm dialated, what stage and phase of labor is she in?

Stage One, Latent(Early) Phase

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? 1. Contractions will be stronger and more uncomfortable and will peak more abruptly. 2. Contractions will be weaker, longer, and more effective. 3. Contractions will be stronger, shorter, and less uncomfortable. 4. Contractions will be stronger and shorter and will peak more slowly.

Answer: 1 RATIONALES: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.

Which of the following describes the term fetal position? 1. Relationship of the fetus's presenting part to the mother's pelvis 2. Fetal posture 3. Fetal head or breech at cervical os 4. Relationship of the fetal long axis to the mother's long axis

Answer: 1 RATIONALES: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.

Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration? 1. Oxytocin causes water intoxication. 2. Oxytocin causes excessive thirst. 3. Oxytocin is toxic to the kidneys. 4. Oxytocin has a diuretic effect.

Answer: 1 RATIONALES: The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

A laboring mom is 9 cm dilated and experiencing contractions every 2 minutes for 90 seconds each. Which stage and phase of labor is she in?

Stage One, Transition Phase

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which of the following would be the most appropriate response? a) "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem." b) "I have never read or heard of this happening." c) "The injection is given in the space outside the spinal cord." d) "An injury is unlikely because of expert professional care given."

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

Which of the following would be an inappropriate indication of placental detachment? 1. An abrupt lengthening of the cord 2. An increase in the number of contractions 3. Relaxation of the uterus 4. Increased vaginal bleeding

Answer: 3 RATIONALES: Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.

While waiting for the placenta to deliver during the third stage of labor you must assess the new mother's vital signs every 15 minutes. What signs would indicate impending shock? a) Bradypnea and hypertension b) Tachypnea and a widening pulse pressure c) Bradycardia and auscultation of fluid in the base of the lungs d) Tachycardia and a falling blood pressure

Tachycardia and a falling blood pressure Correct Explanation: 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; immediately report these signs.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions? 1. Hypertension 2. Jaundice 3. Dehydration 4. Fluid overload 5. Uterine tetany 6. Bradycardia

Answer: 1,4,5 RATIONALES: Adverse reactions to oxytocin in the mother include hypertension, fluid overload, and uterine tetany. The antidiuretic effect of oxytocin increases renal reabsorption of water, leading to fluid overload — not dehydration. Jaundice and bradycardia are adverse reactions that may occur in the neonate. Tachycardia, not bradycardia, is reported as a maternal adverse reaction.

The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones for which reason? 1. To determine fetal well-being 2. To assess for fetal bradycardia 3. To assess fetal position 4. To prepare for an imminent delivery

Answer: 2 RATIONALES: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? 1. Active phase 2. Latent phase 3. Expulsive phase 4. Transitional phase

Answer: 2 RATIONALES: The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.

A client in the fourth stage of labor asks to use the bathroom for the first time since delivery. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best? 1. "You'll have to wait until the vaginal bleeding stops." 2. "You'll have to wait until the oxytocin is infused." 3. "You may use the bathroom with my assistance." 4. "You may get up to the bathroom whenever you need to."

Answer: 3 RATIONALES: The nurse should tell the client that she may use the bathroom with the nurse's assistance. The nurse should assist the client for the client's first trip to the bathroom after delivery. It isn't uncommon for a client to faint after delivery. Telling the client she must wait until her vaginal bleeding stops is inappropriate; vaginal bleeding continues for about 6 weeks after delivery. The nurse shouldn't tell the client she can get up whenever she needs to use the bathroom; doing so places the client at risk for injury.

A primigravid client is admitted to the labor and delivery area. Assessment reveals that she's in the early part of the first stage of labor. Her pain is likely to be most intense: 1. around the pelvic girdle. 2. around the pelvic girdle and in the upper legs. 3. around the pelvic girdle and at the perineum. 4. at the perineum.

Answer: 1 RATIONALES: During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum.

The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? 1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry 2. Acidic pH of fluid when tested with nitrazine paper 3. Presence of amniotic fluid in the vagina 4. Cervical dilation of 6 cm 5. Alkaline pH of fluid when tested with nitrazine paper

Answer: 1,3,5 RATIONALES: The fernlike pattern that occurs when vaginal fluid is placed on a glass slide and allowed to dry, presence of amniotic fluid in the vagina, and alkaline pH of fluid are all signs of ruptured membranes. The fernlike pattern seen when the fluid is allowed to dry on a slide is a result of the high sodium and protein content of the amniotic fluid. The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac. Cervical dilation and regular contractions are signs of progressing labor but don't indicate PROM.

Several minutes after a vaginal delivery, nursing assessment reveals blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition? 1. Cervical or vaginal laceration 2. Placental separation 3. Postpartum hemorrhage 4. Uterine involution

Answer: 2 RATIONALES: Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered.

During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by: 1. applying counterpressure to the fetus's head. 2. encouraging the client to push. 3. massaging and supporting the perineum. 4. instructing the client to contract the perineal muscles.

Answer: 3 RATIONALES: The nurse can help control a precipitous delivery by stretching the labia, such as by massaging and bracing the perineum with gentle back pressure. This helps prevent perineal lacerations — the primary maternal complication of precipitous delivery. Applying counterpressure to the fetus's head reduces perineal stress temporarily; however, delivery proceeds when the client pushes with uterine contractions. Pushing puts further stress on the perineum, promoting delivery. When the fetus's head exerts pressure on the perineum, contracting the perineal muscles is virtually impossible.

A woman states that she does not want any medication for pain relief during labor. Her doctor has approved this for her. What is your best response to her concerning this choice? a) "I respect your preference whether it is to have medication or not." b) "Your doctor (a man) has never been in labor; he may be underestimating the pain you will have." c) "That's wonderful. Medication during labor is not good for the baby." d) "Let me get you something for relaxation if you don't want anything for pain."

"I respect your preference whether it is to have medication or not." Correct Explanation: Individualizing care to meet women's specific needs is a nursing responsibility.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "how would that stop my pain?" Which of the following explanations should the nurse give? a) "It disrupts the nerve signal of pain via mechanical irritation of the nerves." b) "It blocks the transmission of nerve messages of pain at the receptors." c) "It causes the release of endorphins." d) "It distracts your brain from the sensations of pain."

"It distracts your brain from the sensations of pain." Correct Explanation: Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

Opioids are often used in labor for pharmacologic pain management. A patient in the transition phase of labor is requesting fentanyl (Sublimaze) for pain. How should the nurse respond to her request? a) "I will page the provider and ask for your pain medication." b) "You are so close to delivery; don't you want to have natural child birth?" c) "Rather than use fentanyl, we can ask the provider to order another analgesic at this point." d) "Pain medication given now might cause the baby to have slow respirations and is not recommended, let's try to focus and breathe."

"Pain medication given now might cause the baby to have slow respirations and is not recommended, let's try to focus and breathe." Correct Explanation: Once the woman has entered into the transition phase of labor, she is considered to be imminent for delivery. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.

A woman refuses to have an epidural block because she does not want to have a spinal headache after delivery. Which of the following would be your best response? a) "Spinal headache is not a usual complication of epidural blocks." b) "The pain relief offered will compensate for the discomfort afterward." c) "Your doctor knows what is best for you." d) "The anesthesiologist will do her best to avoid this."

"Spinal headache is not a usual complication of epidural blocks." Correct Explanation: Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

After pitocin is administed, how often is it increased determining on dilation and effacement?

1-2mu per 15 min 20 mu max. 30 mu max with physician orders

What are the 3 types of cesarean section cuts that can be made. What are their advantages?

1. Kerr (Transverse) : Allows VBAC for 2nd birth 2. Selheim : Low incision 3. Classical : Fastest(Risk or Trauma), Dihisance Risk, No vaginal supsequent births.

What three test are done to confirm a rupture of the amniotic membranes?

1. Nitrazine Paper (Turn blue to change in pH) 2. Ferning Test (Fluid dried shows fern like design) 3. Free Flow (Cervical exam, pt asked to bear down, fluid seen on cervix)

The expected fetal heart rate response in an active fetus is which of the following: a) Deceleration followed by acceleration of 15 bpm b) Decrease in variability for 15 seconds c) Acceleration of at least 15 bpm for 15 seconds d) Increase in variability by 15 bpm

Acceleration of at least 15 bpm for 15 seconds Explanation: A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which of the following? a) Diastole b) Decrement c) Increment d) Acme

Acme Correct Explanation: The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction

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 form of therapy as which of the following? a) Biofeedback b) Effleurage c) Acupuncture d) Acupressure

Acupressure Correct Explanation: Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for childbirth classes is a classic example of therapeutic touch. Biofeedback is based on the belief people have control and can regulate internal events such as heart rate and pain responses.

Susan is in labor with her second child. She knows that she will want epidural anesthesia and she has already signed her consent form. What must the nurse do before Susan receives the epidural? a) Administer a fluid bolus through the IV line to reduce the risk of hypotension b) Prepare a sterile field with the supplies and medications that will be needed c) Review Susan's medical history and laboratory results, and interview Susan to confirm all information is accurate and up to date d) Place Susan in the fetal position on the table and keep her steady so that she won't move during the procedure

Administer a fluid bolus through the IV line to reduce the risk of hypotension Explanation: Epidurals can cause vasodilatation and result in hypotensive episodes, IV fluid bolus prior to epidural placement can help prevent the hypotensive episode. She has signed the consent form, so it is unnecessary to interview her again. Do not place her in the fetal position or prep the site until the anesthesiologist arrives; then, assist them.

During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide? 1. Blood pressure reflects changes in cardiovascular function, which may affect the fetus. 2. Increased blood pressure indicates that the client is experiencing pain. 3. Increased blood pressure signals the peak of the contraction. 4. Medications given during labor affect blood pressure.

Answer: 1 RATIONALES: Frequent blood pressure measurement helps determine whether maternal cardiovascular function is adequate. During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased blood pressure is expected during pain and contractions. Measuring blood pressure frequently helps determine whether blood pressure has returned to precontraction levels, ensuring adequate blood flow to the fetus. Although medications given during labor can affect blood pressure, the main purpose of measuring blood pressure is to verify adequate fetal status.

The nurse is administering oxytocin (Pitocin) to a client in labor. During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely? 1. Because oxytocin causes fluid retention 2. Because oxytocin causes excessive thirst 3. Because oxytocin has a diuretic effect

Answer: 1 RATIONALES: Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Excessive thirst results from the work of labor and lack of oral fluids, not oxytocin administration. Oxytocin isn't toxic to the kidney.

When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? 1. Fetal hypoxia 2. The contraction pattern 3. The status of a trapped cord 4. Maternal comfort

Answer: 1 RATIONALES: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? 1. Change the client's position. 2. Prepare for emergency cesarean section. 3. Check for placenta previa. 4. Administer oxygen.

Answer: 1 RATIONALES: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.

At 40 weeks' gestation, a client is admitted to the labor and delivery area. She and her husband are worried about the fetus's health because she had problems during her previous childbirth. The nurse reassures them that the fetus will be monitored closely with an electronic fetal monitor (EFM). On the fetal monitor strip, what is the single most reliable indicator of fetal well-being? 1. Normal long-term variability 2. Normal short-term variability 3. Normal baseline fetal heart rate (FHR) 4. Normal contraction sequence

Answer: 2 RATIONALES: Normal short-term variability — 2 to 3 beats per amplitude — is the single most reliable indicator of fetal well-being on an EFM strip. It represents actual beat-to-beat fluctuations in the FHR. Normal long-term variability, although a helpful indicator, takes into account larger periodic and rhythmic deviations above and below the baseline FHR. Baseline FHR serves only as a reference for all subsequent FHR readings taken during labor. Contraction sequence provides no information about fetal well-being, although it does give some indication of maternal well-being and progress.

When caring for a client with preeclampsia, which action is a priority? 1. Monitoring the client's labor carefully and preparing for a fast delivery 2. Continually assessing the fetal tracing for signs of fetal distress 3. Checking vital signs every 15 minutes to watch for increasing blood pressure 4. Reducing visual and auditory stimulation

Answer: 4 RATIONALES: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.

A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. Her latent phase may be considered prolonged after: 1. 6 hours. 2. 10 hours. 3. 14 hours. 4. 20 hours.

Answer: 4 RATIONALES: Based on research, the latent phase may be considered prolonged if it exceeds 20 hours in a nulliparous client or 14 hours in a multiparous client.

Using the acronym COAT or TOCA, what is the nurse assessing and what are important to ask the client?

Assessing the amniotic fluid after the bag of membranes has been broken. • C : Color (Clear, Blood Tinged, Green Meconium) • O : Odor (Possible Infection) • A : Amount (Trickle (scant), Copius, Moderate) • T : Time (When? To prevent infection labor within 24 hrs.)

The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded and distended, non-tender. What intervention should the nurse take next? a) Assume this is part of the uterus b) Check the chart for the last void c) Ask the patient if the mass has always been present d) Notify a physician about the mass

Check the chart for the last void Correct Explanation: The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the patient and offer to assist the patient to void or prepare to catheterize the patient to empty the bladder. This can be taken care of by the nurse. The patient would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.

During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus how often? a) Every 5 minutes b) Every 15 minutes c) Every 10 minutes d) Every 20 minutes

Every 15 minutes Correct 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.

During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent and the baseline FHR is within normal limits. What should you do first? a) Help the woman change positions b) Discontinue supplemental oxygen c) Start an oxytocic infusion and decrease the rate of IV fluids d) Position the woman on her side with a pillow under her left hip

Help the woman change positions Correct Explanation: Changing positions is a first intervention to determine if this will improve the oxygen to the fetus. Supplemental oxygen should be maintained until the mother is stable. Placing the patient on her side may increase the work of breathing. Pharmacological interventions are premature.

The following are nursing measures commonly offered to women in labor. Which nursing intervention would probably be most effective in applying the gate control theory for relief of labor pain? a) Give the prescribed medication b) Encourage the woman to rest between contractions c) Change the woman's position d) Massage for the woman's back

Massage for the woman's back Correct 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 patient. Medication should be withheld until all non-pharmacological treatments have been exhausted.

A nurse is caring for a client who has just received an epidural. Which of the following is the MOST common side effect of epidural anesthesia? a) Maternal hypotension, which can lead to fetal tachycardia b) Maternal hypertension, which can lead to fetal bradycardia c) Maternal hypertension, which can lead to fetal tachycardia d) Maternal hypotension, which can lead to fetal bradycardia

Maternal hypotension, which can lead to fetal bradycardia Correct Explanation: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia.

The amniotic fluid is green when the membranes rupture. What finding would the nurse document? a) Umbilical cord prolapse b) Meconium in the amniotic sac c) Amniotic fluid embolism d) Infection

Meconium in the amniotic sac Correct Explanation: Green tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by puss or cloudy fluid. Umbilical cord prolapse occurs when pressure on the cord stops the flow of oxygen to the fetus. Amniotic embolism results when amniotic fluid enters circulation.

If there has been a SROM or AROM, how often should the nurse take vital signs?

Q 2hrs.

Which of the following is NOT an opioid that is commonly used during labor and delivery? a) Nalbuphine (Nubain) b) Secobarbital (Seconal) c) Meperidine (Demerol) d) Butorphanol (Stadol)

Secobarbital (Seconal) Correct Explanation: Meperidine, butorphanol, and nalbuphine are opioids that are commonly used during labor and delivery. Secobarbital is a barbiturate.

Which instructions should be given by the nurse to the patient in the second stage of labor to facilitate natural childbirth? a) Use a squatting position and use the squat bar for support b) Stay low on her back to ease the back pain c) Use the Valsalva maneuver for effective pushing d) Ask for privacy and have just the partner present

Use a squatting position and use the squat bar for support Correct Explanation: The position is very important during labor. The woman needs to be in a position of comfort. Allowing the woman to assume the most comfortable position will facilitate natural childbirth. The Valsalva maneuver may result in dangerous increases in blood pressure, so be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.

While caring for woman in labor the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is: a) Cord compression b) Uteroplacental insufficiency c) Maternal fatigue d) Maternal hypotension

Uteroplacental insufficiency Explanation: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia

Question: During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence. -4 station +2 station +4 station 0 station -2 station

-4 station -2 station 0 station +2 station +4 station Correct Explanation: Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured when the result is which of the following? a) 5.5 b) 6.5 c) 5.0 d) 6.0

6.5 Correct Explanation: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? a) Administration of aspirin b) Administration of 500 mL of IV Ringer's lactate c) Administration of 1000 mL of IV glucose solution d) Move the woman into a supine position

Administration of 500 mL of IV Ringer's lactate Correct Explanation: The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution, because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain a woman does not lie supine but remains on her side after an epidural block, to help prevent supine hypotension syndrome. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself.

Jennifer has just received IV sedation. What must the nurse tell Jennifer to do? a) Ambulate within 15 minutes to prevent spinal headache b) Ambulate only with assistance from the nurse or caregiver c) Sit on the edge of the bed with her feet dangling before ambulating d) Remain in bed for at least 30 minutes

Ambulate only with assistance from the nurse or caregiver Correct Explanation: The patient may have decrease sensory from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.

Which of the following would be the best way the nurse can facilitate an effective birth plan for the patient to achieve adequate pain relief? a) The nurse prescribes alternative methods of pain relief b) The health care provider decides the best pain relief for the mother and family c) The client has the baby without any analgesic or anesthetic d) Client priorities and preferences are incorporated into the plan

Client priorities and preferences are incorporated into the plan Correct Explanation: The nurse and the patient would work together; the nurse needs to seek information on the desires of the patient and work to achieve the desired level of pain control for the labor and delivery experience.

A woman is experiencing back labor and complains of intense pain in the lower back. Which is the most effective nursing intervention to relieve this type of pain? a) Effleurage of the abdomen during the contraction b) Counter pressure against the sacrum c) Conscious relaxation/guided imagery in low fowlers d) Pant-blow (breaths and puffs breathing techniques)

Counter pressure against the sacrum Correct Explanation: Counter pressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as is conscious relaxation. Breathing will not diminish the pain of back labor.

Mrs. Timms is now in the transition phase of labor. One of your concerns is the possibility of an ineffective breathing pattern. If one of your goals was for the woman's breathing pattern to be effective, what outcome would you expect? a) Uses accelerated breathing patterns continuously b) Refrains from using the pant-blow technique so she doesn't push c) Does not hyperventilate d) Pants through each contraction as she pushes

Does not hyperventilate Correct Explanation: 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.

Beverly is being admitted to labor and delivery. When admitting an obstetric patient in early labor, the first intervention by the nurse is: a) Good rapport is established with the patient and significant other b) Perineal shave is done immediately to prepare for the examination c) Vital signs and FHR are assessed by internal electronic monitoring d) The personal belongings are properly checked and secured

Good rapport is established with the patient and significant other Correct Explanation: On admission the patient and her family need to establish a rapport with their caregiver. If the patient is stable and there is no immediate need, rapport should be established over actions that can be taken care of later.

The nurse is assisting Monica through labor, monitoring her closely, now that she has received an epidural. The nurse would report which finding to the anesthesiologist? a) Rapid progress of labor b) Urinary retention c) Dry, cracked lips d) Inability to push

Inability to push Correct Explanation: If she is not able to push, her epidural dose may be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so you should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

At which time during a woman's labor might the nurse assist with a pudendal block? a) Before dilation only b) Just before delivery c) Just after delivery d) Early stage labor

Just before delivery Correct Explanation: Pudendal block is a local block in the perineal area and is used to numb for delivery. Application before labor begins or while it is in the early stages would be counterproductive, as the patient would not have proper feeling and would have a harder time pushing. After delivery it is pointless; the most painful part is over.

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: a) Right upper quadrant b) Left lower quadrant c) Left upper quadrant d) Right lower quadrant

Left lower quadrant Correct 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.

You place an external fetal monitor on a woman in labor. Which of the following instructions would be best to give her? a) Avoid flexing her knees so her abdomen is not tense. b) Lie supine so the tracing does not show a shadow. c) Avoid using her call bell to reduce interference. d) Lie on her side so she is comfortable.

Lie on her side so she is comfortable. Correct Explanation: The best position for all women during labor is on their side.

Nancy has presented in the early phase of labor. She's experiencing abdominal pain and shows signs of growing anxiety about the pain. What is the best pain management technique the nurse can suggest at this stage? a) Administering an opioid such as meperidine (Demerol) or fentanyl (Sublimaze) b) Immersing Nancy in warm water in a pool or hot tub c) Practicing effleurage on the abdomen d) Administering a sedative such as secobarbital (Seconal) or pentobarbital (Nembutal)

Practicing effleurage on the abdomen Correct Explanation: In early labor, the less medication use the better, allow use of nonpharmacologic management and control the pain with gate theory. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

Which of the following signs signify that the second stage of labor has begun? a) Emotions are calm and happy b) Frequency of contractions are 5-6 minutes c) The urge to push occurs d) Fetus is a -1 station

The urge to push occurs Correct 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. 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 nurse instructs the patient about skin massage and the gate-control theory of pain. Which of the following statements would be appropriate for the nurse to include for patient understanding of the nonpharmacological pain-relief methods? a) The gate control mechanism opens so all the stimuli pass through to the brain. b) This is a technique to prevent the painful stimuli from entering the brain. c) The gate control mechanism is located at the pain site. d) Pain perception is decreased if anxiety is present.

This is a technique to prevent the painful stimuli from entering the brain. Correct Explanation: Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location.

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? a) Women report higher levels of satisfaction when regional anesthetics are used to control pain b) Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience c) Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain d) Women report higher levels of satisfaction when the physician makes the decision on what type of pain control to use

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience Correct Explanation: Research has shown that women report higher levels of satisfaction with their labor experience when they feel a high degree of control over the experience of pain (Stuebe & Barbieri, 2005).

To assess the frequency of a woman's labor contractions, you would time a) how many contractions occur in 5 minutes. b) the interval between the acme of two consecutive contractions. c) the end of one contraction to the beginning of the next. d) the beginning of one contraction to the beginning of the next.

the beginning of one contraction to the beginning of the next. Correct Explanation: Measuring from the beginning of one contraction to the next marks the time between contractions.

What is pitocin drug half-life and where should it be administered and why?

• 6 min. 1/2 life • Closest port to IV site • To provide tight control of medication infusion

A woman at 39 weeks gestation has been in labor for 8 hours and is asking how far she is dilated, she attended child birth classes and is aware of the stages and phases of labor. She had a vaginal exam 30 minutes prior to her asking again. How should the nurse respond to her question? a) "Checking your cervix will not speed up labor, let's wait." b) "The health care provider will have to check you, we can call them." c) "I can arrange for a cervix check, if you want." d) "You labor signs have not changed; we are looking for changes in your labor pattern before we check you again."

"You labor signs have not changed; we are looking for changes in your labor pattern before we check you again." Correct Explanation: The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The patient has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her.

For a client who's fully dilated, which of the following actions would be inappropriate during the second stage of labor? 1. Positioning the mother for effective pushing 2. Preparing for delivery of the baby 3. Assessing vital signs every 15 minutes 4. Assessing for rupture of membranes

Answer: 4 RATIONALES: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.

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? a) Effleurage b) Abdominal imagery c) Massage d) Pain pathway blockage

Effleurage Correct Explanation: Effleurage, a form of touch that involves light circular fingertip movements on the abdomen, 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.

A woman in labor at the hospital has just received an epidural block. Which intervention is priority before and during epidural placement? a) Increase oral fluids every hour to prevent dehydration b) Monitor temperature every four hours and give Tylenol if 100.4 c) Monitor the maternal apical pulse for Bradycardia d) Provide adequate IV fluids to maintain her blood pressure

Provide adequate IV fluids to maintain her blood pressure Correct Explanation: The patient will need to have a bolus of IV fluids prior to and then maintained during the epidural to be prepared in the event of the hypotensive episodes that may accompany epidural placement. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature, but wait for instructions from the doctor as to when to administer medication. Bradycardia is not a common side effect of epidural medication

Opioids are the most frequently used medications to provide analgesia during labor. Which of the following drugs is an opioid that is used in obstetrics for relief of labor pain? a) Sublimaze b) Ultram c) Carbamazepine d) Toradol

Sublimaze Explanation: Opioids, medications with opium-like properties (also known as narcotic analgesics), are the most frequently administered medications to provide analgesia during labor. Opioids, such as meperidine (Demerol) and fentanyl (Sublimaze), frequently assist the woman to better tolerate labor contractions by causing relaxation and sleep between contractions (Grant, 2006b). Opioids are most frequently given by the intravenous (IV) route because this route provides fast onset and more consistent drug levels than do the subcutaneous or intramuscular routes.

What is the most important thing that you can do during labor and delivery to prevent maternal and fetal infection? a) Clean the woman's perineum with a Betadine scrub b) Thoroughly wash your hands before and after patient contact c) Strictly follow universal precautions d) Remove soiled drapes and linen; place an absorbent pad under the buttocks and two sterile perineal pads against the perineum

Thoroughly wash your hands before and after patient contact Correct Explanation: The most important infection control technique in any health care setting is thoroughly washing hands on routine basis. Keeping the area clean is secondary, but is also important.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. Which of the following should the nurse do? a) Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor b) Agree with the client and administer the drug immediately to keep the pain manageable c) Refuse to administer narcotics, because they can develop dependency in the client and the fetus d) Explain to the client that narcotics should only be administered an hour or less before birth

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

Jennifer has just received IV sedation. What must the nurse tell Jennifer to do? a) Ambulate only with assistance from the nurse or caregiver b) Sit on the edge of the bed with her feet dangling before ambulating c) Remain in bed for at least 30 minutes d) Ambulate within 15 minutes to prevent spinal headache

Ambulate only with assistance from the nurse or caregiver Correct Explanation: The patient may have decrease sensory from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.

Which of the following is true regarding analgesia versus anesthesia? a) Decreased FHR variability is a common side effect when regional anesthesia is used. b) Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. c) Hypotension is the most common side effect when systemic analgesia is used. d) Regional anesthesia should be given with caution close to the time of delivery because it crosses the placenta and can cause respiratory depression in the newborn.

Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. Correct Explanation: Systemic analgesia should be used with caution near the time of delivery because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action? 1. Assess for presence of a full bladder. 2. Suggest the placement of an internal uterine pressure catheter to determine adequacy of contractions. 3. Encourage the mother to relax by assisting her with appropriate breathing techniques. 4. Suggest to the physician that oxytocin augmentation be started to stimulate labor.

Answer: 1 RATIONALES: A full bladder will slow or stop cervical dilation and produce symptoms that could be misdiagnosed as arrest in labor. Other strategies, such as internal uterine monitoring, relaxation, and oxytocin augmentation, would be appropriate later, but assessing the bladder first is key.

The nurse observes a late deceleration. It's characterized by and indicates which of the following? 1. U-shaped deceleration occurring after the first half of the contraction, indicating uteroplacental insufficiency 2. U-shaped deceleration occurring with the contraction, indicating cord compression 3. V-shaped deceleration occurring after the contraction, indicating uteroplacental insufficiency 4. Deep U-shaped deceleration occurring before the contraction, indicating head compression

Answer: 1 RATIONALES: A late deceleration is U-shaped and occurs after the first half of the contraction, indicating uteroplacental insufficiency. It's an ominous pattern and requires immediate action — such as administering oxygen, repositioning the mother, and increasing the I.V. infusion rate — to correct the problem. U- and V-shaped decelerations are variable decelerations occurring at unpredictable times during contractions and are related to umbilical cord compression. Deep U-shaped deceleration occurring before the contraction is early deceleration.

For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care? 1. Offer support by reviewing the short-pant form of breathing. 2. Administer narcotic analgesia. 3. Allow the mother to walk around the unit. 4. Watch for rupture of the membranes.

Answer: 1 RATIONALES: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions and reduce the need for opioids and other forms of pain relief, which can have an effect on fetal outcome. In the active phase, the mother most likely is too uncomfortable to walk around the unit. The nurse will observe for rupture of membranes and may administer opioid analgesia but these don't take priority.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation? 1. Breech position 2. Late decelerations 3. Entrance into the second stage of labor 4. Multiple gestation

Answer: 1 RATIONALES: Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do? 1. Have the client void. 2. Assess the client's vital signs. 3. Evaluate lochia characteristics. 4. Massage the fundus.

Answer: 1 RATIONALES: Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. In a client who doesn't have a full bladder, the nurse should evaluate lochia characteristics to detect possible hemorrhage. If the client has a full bladder, massaging the fundus won't stimulate uterine contractions (which aid uterine involution) or prevent uterine atony — a possible cause of hemorrhage.

The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following must occur? 1. The membranes must rupture. 2. The client must receive anesthesia. 3. The cervix must be fully dilated. 4. The fetus must be at 0 station.

Answer: 1 RATIONALES: Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at -1 station. Anesthesia isn't required for internal EFM.

A client, age 19, goes into labor at 40 weeks' gestation. When assessing the fetal monitor strip, the nurse sees that the fetal heart rate (FHR) has decreased to 60 beats/minute and that the waveforms sometimes resemble a V and begin and end abruptly. The nurse should interpret this pattern as: 1. variable decelerations. 2. decreased short-term variability. 3. increased long-term variability. 4. early decelerations.

Answer: 1 RATIONALES: On a fetal monitor strip, variable decelerations are characterized by an FHR that commonly decreases to 60 beats/minute; waveform shapes that vary and may resemble the letter U, V, or W; and deceleration waveforms with an abrupt onset and recovery. Decreased short-term variability manifests as fewer than 2 to 3 beats/amplitude of the baseline FHR. Increased long-term variability manifests as more than 5 to 20 beats/minute of the baseline FHR in rhythmic fluctuation. Early decelerations are seen as the descent, peak, and recovery of the deceleration waveform that mirrors the contraction waveform.

At 28 weeks' gestation, a client is admitted to the labor and delivery area in preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client outcome reflects the nurse's awareness of an adverse effect of ritodrine? 1. "The client remains free from tachycardia." 2. "The client remains free from polyuria." 3. "The client remains free from hypertension." 4. "The client remains free from hyporeflexia."

Answer: 1 RATIONALES: Ritodrine and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or hyporeflexia.

A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer: 1. ritodrine (Yutopar). 2. bromocriptine (Parlodel). 3. magnesium sulfate. 4. betamethasone (Celestone).

Answer: 1 RATIONALES: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B2 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia — a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).

A diabetic client in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest? 1. Diabetic ketoacidosis 2. Hypoglycemia 3. Infection 4. Transition to the active phase of labor

Answer: 1 RATIONALES: Signs and symptoms of diabetic ketoacidosis include nausea and vomiting, a fruity or acetone breath odor, signs of dehydration (such as flushed, dry skin), hyperglycemia, ketonuria, hypotension, deep and rapid respirations, and a decreased level of consciousness. In contrast, hypoglycemia causes sweating, tremors, palpitations, and behavioral changes. Infection causes a fever. Transition to the active phase of labor is signaled by cervical dilation of up to 7 cm and contractions every 2 to 5 minutes.

The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan? 1. Anxiety related to the facility environment 2. Fear related to a potentially difficult childbirth 3. Compromised family coping related to hospitalization 4. Acute pain related to labor contractions

Answer: 2 RATIONALES: A client's ability to cope during labor and delivery may be hampered by fear of a painful or difficult childbirth, fear of loss of control or self-esteem during childbirth, or fear of fetal death. A previous negative experience may increase these fears. Therefore, Fear related to a potentially difficult childbirth is the most appropriate nursing diagnosis. The client's anxiety stems from her past history of a long labor, not from being in the facility; therefore a diagnosis of Anxiety related to the facility environment isn't warranted. There is no evidence of compromised family coping related to hospitalization. Although acute pain related to labor contractions may be a problem, this isn't mentioned in the question.

When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be which of the following? 1. Shorter than her first labor 2. About half as long as her first labor 3. About the same length of time as her first labor 4. A length of time that can't be determined based on her first labor

Answer: 2 RATIONALES: A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect.

During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority? 1. Deficient knowledge (testing procedure) related to amniotomy 2. Ineffective fetal cerebral tissue perfusion related to cord compression 3. Acute pain related to increasing strength of contractions 4. Risk for infection related to rupture of membranes

Answer: 2 RATIONALES: Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Acute pain, and Risk for infection.

A client with Rh isoimmunization delivers a neonate with an enlarged heart and severe, generalized edema. Which nursing diagnosis is most appropriate for this client? 1. Ineffective denial related to a socially unacceptable infection 2. Impaired parenting related to the neonate's transfer to the intensive care unit 3. Deficient fluid volume related to severe edema 4. Fear related to removal and loss of the neonate by statute

Answer: 2 RATIONALES: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client lacks signs and symptoms of this disease. What is the significance of this finding? 1. Maternal gonorrhea may cause a neural tube defect in the fetus. 2. Maternal gonorrhea may cause an eye infection in the neonate. 3. Maternal gonorrhea may cause acute liver changes in the fetus. 4. Maternal gonorrhea may cause anemia in the neonate.

Answer: 2 RATIONALES: Gonorrhea in the cervix may cause neonatal eye infection during delivery as well as a serious puerperal infection in the client. Maternal gonorrhea isn't associated with neural tube defects, acute fetal liver changes, or neonatal anemia.

A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: 1. uterine inversion. 2. uterine atony. 3. uterine involution. 4. uterine discomfort.

Answer: 2 RATIONALES: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

The nurse notices that a large number of clients who receive oxytocin (Pitocin) to induce labor, vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? 1. Notify the physicians and explain that they need to teach their clients before inducing labor. 2. Initiate a unit policy involving staff nurses, certified nurse midwives, and physicians in teaching clients before labor induction. 3. Report the physicians for providing inferior care. 4. Initiate a protocol order that allows the nurse to administer promethazine (Phenergan) before administering oxytocin.

Answer: 2 RATIONALES: The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Option 1 blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the problem — the lack of client education.

An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl, hemoglobin 14.5 g/dl, hematocrit 40%, and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority? 1. Notifying the laboratory that a repeat hemoglobin and hematocrit have been ordered. 2. Recommending that the client drink plenty of fluids. 3. Consulting with the infection control nurse. 4. Asking the client if she has been exposed to varicella in the past 3 weeks.

Answer: 3 RATIONALES: A nontreponemal test screens the client for syphilis. The positive test result, along with the lymphadenopathy and rash, indicate that the client has secondary syphilis. Based on these findings, the neonate will most likely have signs and symptoms of congenital syphilis. The hemoglobin and hematocrit results are normal for a pregnant client. The laboratory results don't show signs of dehydration, so having the client drink plenty of fluids isn't necessary. The lesions associated with varicella are vesicular, and don't resemble the rash associated with syphilis.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? 1. Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. 2. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. 3. Notify the physician and security immediately. 4. Ask the nursing assistant to dispose of the marijuana that the client can't smoke anymore.

Answer: 3 RATIONALES: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security who are specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. Who should the nurse manager consult to help the staff cope with this unexpected death? 1. The human resource director, so she can arrange vacation time for the staff 2. The physician, so he can provide education about HELLP syndrome 3. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff 4. The chaplain, because his educational background includes strategies for handling grief

Answer: 4 RATIONALES: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

Betsy is recovering from a standard delivery. The nurse has just removed Betsy's epidural catheter and applied a sterile pressure dressing. What is it important for the nurse to do now? a) Make sure that Betsy receives plenty of fluids b) Help Betsy to get up and walk around immediately c) Let Betsy rest and recover while keeping her legs slightly elevated d) Assess return of sensory and motor functions to the lower extremities

Assess return of sensory and motor functions to the lower extremities Correct Explanation: After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time; at least until the medication wears off. Do not elevate the legs; you want to maintain normal circulation. Fluids are important, but they are not related to the epidural or to the metabolism of the medication.

A pregnant client mentions to the nurse that a friend has given her a variety of herbs to use during her upcoming labor to help manage pain. Specifically, she gave her chamomile tea, raspberry leaf tea, skullcap, catnip, jasmine, lavender, and black cohosh. Which of these should the nurse encourage the client not to take because of the risk of acute toxic effects such as cerebrovascular accident? a) Skullcap b) Catnip c) Jasmine d) Black cohosh

Black cohosh Explanation: Several herbal preparations have traditionally been used to reduce pain with dysmenorrhea or labor, although there is little evidence-based support for their effectiveness. Examples include chamomile tea for its relaxing properties; raspberry leaf tea (women freeze it into ice cubes to suck on), which is thought to strengthen uterine contractions; skullcap and catnip, which are thought to help with pain. Jasmine and lavender may both be mixed into oils and rubbed on the perineum before and during labor to soften the muscle and help prevent perineal tears. Black cohosh (squaw root), an herb that induces uterine contractions, is not recommended because of the risk of acute toxic effects such as cerebrovascular accident to the mother or fetus.

You are the nurse preparing an educational event for pregnant women on the topic of labor pain and delivery. You know that you will need to include the origin of labor pain for each stage of labor. What information will you present for the first stage of labor? a) Diffuse abdominal pain signals a complication with progression of labor b) It is reported as the worst pain you will ever feel c) Pain is focal in nature d) Pain originates from the cervix and lower uterine segment

Pain originates from the cervix and lower uterine segment Correct 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.

Joanne has been in labor for 5 hours. Earlier there was a gradual increase in FHR baseline with variables, but Joanne has changed position several times and now the fetus shows no signs of hypoxia. Joanne's cervix is almost completely effaced and is dilated to 8 cm. However, the labor graph indicates that the fetus has stopped descending. What should you do first? a) Alert the team that internal fetal monitoring may be needed b) Institute effleurage and apply pressure to Joanne's lower back during contractions c) Encourage Joanne to push d) Palpate the area just above the symphysis pubis

Palpate the area just above the symphysis pubis Correct Explanation: Palpate to determine if the infant is engaged and what the presenting part of the infant is by the symphysis pubis, it is possible for infants to rotate and change position during labor. Assess the situation and act further if necessary, but until you have more information on fetal position, assume all is going well.

According to Ballard assessment scale, what size determines and large for gestational age baby and a small for gestational age baby? What measurements are used to get to this score?

>90% growth = LGA <10% growth = SGA 1. Head Circumference 2. Crown to Rump Distance 3. Femur Length

Early in labor, a pregnant client asks why contractions hurt so much. Which of the following should the nurse mention? a) Distraction of the brain cortex by other stimuli b) Release of endorphins in response to contractions c) Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels d) Blocking of nerve transmission via mechanical irritation of nerve fibers

Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Correct Explanation: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

What concentrations do Pitocin usually come in?

30u/500L 20u/1000L 10u/1000L

A nurse is serving as a doula to a client who is now in labor at an alternative birthing center. The client has opted for a water birth, and the nurse is now drawing the water into a large tub. What temperature should the nurse keep the water at? a) 35°C b) 41°C c) 39°C d) 37°C

37°C Correct Explanation: Standing under a warm shower or soaking in a tub of warm water, jet hydrotherapy tub, or whirlpool is another way to apply heat to help reduce the pain of labor. The temperature of water used should be 37°C to prevent hyperthermia of the woman and also the newborn at birth.

The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Answer: 4 RATIONALES: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

During assessment for admission to the labor and delivery area, a client and her husband ask the nurse whether their sons, ages 8 and 10, can witness the childbirth. Before answering this question, the nurse should consider which guideline? 1. The children and client should share a support person during the childbirth. 2. Children should attend childbirth only if it takes place at home. 3. Children shouldn't attend childbirth because it will frighten them. 4. Each child attending the childbirth should have a separate support person.

Answer: 4 RATIONALES: Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.

The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage? 1. Active phase 2. Complete phase 3. Latent phase 4. Transitional phase

Answer: 4 RATIONALES: The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4½ to 6 hours; it's characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

A 30-year-old G2P0010 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 8/10 with each contraction. What should the nurse do first? a) Assist the patient in ambulating to the bathroom. b) Assess for labor progression. c) Instruct the patient to do slow-paced breathing. d) Prepare the patient for an epidural.

Assess for labor progression. Correct Explanation: Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the patient experience a reduction in pain. However, the best first step is to assess the patient for labor progress before assisting her otherwise. Bearing down can be a sign that the patient is 10 cm dilated.

As a woman enters the second stage of labor, which of the following would you expect to assess? a) Feelings of being frightened by the change in contractions b) Complaints of feeling hungry and unsatisfied c) Falling asleep from exhaustion d) Expressions of satisfaction with her labor progress

Feelings of being frightened by the change in contractions Correct Explanation: The nature of contractions changes so drastically to an urge to push that this can be frightening.

How does a woman who feels in control of the situation during labor influence her pain? a) Feelings of control are inversely related to the patient's report of pain. b) There is no association between the two factors. c) Feeling in control shortens the overall length of labor. d) Decreased feeling of control helps during the third stage.

Feelings of control are inversely related to the patient's report of pain. Correct 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.

A laboring client in transition phase is 8 cm dilated and feels the urge to push. What are the risks to the mom and what is the nursing intervention?

Risk of tearing perinium when <10cm dialted • Use open glottis, short breaths when feeling the urge to push.

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 of the following substances is the nurse referring? a) Prostaglandins b) Endorphins c) Progesterone d) Relaxin

Endorphins Correct 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 pregnant client in her 32nd week of gestation has been admitted to a health care center with complaints of decreased fetal movement. Which of the following should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds? a) Fetal back b) Fetal shoulders c) Fetal buttocks d) Fetal head

Fetal back Correct Explanation: 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 the buttocks would be of no help in localizing the heart sounds.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which of the following patterns would you anticipate seeing on the monitor? a) Variable decelerations, too unpredictable to count b) Fetal baseline rate increasing at least 5 mm Hg with contractions c) Fetal heart rate declining late with contractions and remaining depressed d) A shallow deceleration occurring with the beginning of contractions

Fetal heart rate declining late with contractions and remaining depressed Correct Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

Your client is in active labor. When you check the EFM tracing, you note variables that are nonreassuring. What would be your first nursing intervention? a) Obtain assistance to check for a compressed umbilical cord b) Prepare the woman for an emergency C-Section. c) Help the woman change positions d) Document the finding

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

A multigravida is admitted to the hospital in active labor. The client's and the fetus' condition have been good since admission. The client calls out to the nurse, "the baby is coming!" What is the first action of the nurse? a) Contact the physician b) Auscultate the fetal heart tones c) Inspect the perineum d) Time the contractions

Inspect the perineum Correct Explanation: The nurse needs to determine if delivery is imminent and be prepared for delivery. Once the nurse assesses the coming labor, the heart sounds, contraction rate, and contacting the physician can all be done, if there is time.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? a) Fetal hypersensitivity to anesthetic b) Neonatal depression c) Woman is more sensitive to pre-anesthetic medications d) Woman is less sensitive to inhalation anesthetics

Neonatal depression Correct Explanation: General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

A woman dilated to 10 centimeters and feeling the urge to "have a bowel movement" is refusing to push, she is screaming "it hurts down there too much to push." What is the option the nurse should suggest at this point for pain management to facilitate pushing? a) Paracervical block b) Pudendal block c) Parenteral medication d) Epidural anesthesia

Pudendal block Correct Explanation: The patient is too far dilated to have any parenteral medication or an epidural block. The best option is a local block or a pudendal block that will numb the vaginal wall to block the pain sensation to the pudendal nerve. The paracervical block is only used in the first stage of labor and this patient is in the second stage.

As the nurse in an obstetric clinic, you are conducting patient education with a group of expectant mothers. One young woman asks you to tell the group what labor pain is like. What would be your best response? a) It comes in waves. b) The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in. c) It is best evaluated by talking with visitors in the labor room because they know you best. d) It has been described as the worst pain you will ever feel.

The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in. Correct Explanation: Pain sensations associated with labor originate from different places, depending on the stage of labor.

The laboring patient who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. Identify the appropriate rationale for this practice. a) The effects would wear off before delivery. b) This may prolong labor and increase complications. c) This can lead to maternal hypertension. d) This would cause fetal depression in utero.

This may prolong labor and increase complications. Correct Explanation: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The patient should be offered nonpharmacologic options at this point until she is in active labor.

What is the primary role of the nurse in pain management for a nurse working with labor patients? a) Provide any medication the patient request b) Monitor the patient for active labor and suggest she have an epidural to have increased satisfaction with her delivery experience c) Dictate the pain management during labor for the best outcome d) Work with the labor patient to plan pain management options

Work with the labor patient to plan pain management options Correct Explanation: The role of the nurse is to work with the patient and plan with the nurse the pain management technique desired by the patient to meet the level of expectation for the patient. Pain is subjective and each woman has a right to her own labor plan.