Chapter 14: Nursing Management During Labor and Birth

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

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

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

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

Which signs signify that the second stage of labor has begun?

The urge to push occurs. 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 notes that a client's amniotic fluid is green when the membranes rupture. What finding would the nurse document?

meconium in the amniotic sac 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 pus 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.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

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

What is the most important thing a nurse can do during labor and birth to prevent maternal and fetal infection?

Thoroughly wash the hands before and after client contact. 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.

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

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

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

infection Because internal monitoring techniques are invasive, both the woman and the fetus can become ill with infection. Internal methods should be used only when the benefit clearly outweighs the risk.

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

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

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

prolonged decelerations Prolonged decelerations are associated with prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression.

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

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

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain." Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.

A woman asks the nurse if she can eat something during labor. Which response by the nurse would be best?

"You could have some hard candy to suck on." If women are kept NPO during labor, they can be administered anesthesia safely in an emergency. Stomach-emptying time is decreased.

The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?

Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

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

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

A woman arrives in the labor and birth department and is panting and screaming "the baby is coming". What is the priority intervention by the nurse?

Quickly move the woman to a labor bed, and check the perineum. 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.

A woman at 39 weeks gestation has been in labor for 8 hours and is asking how far she is dilated. She attended childbirth 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?

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

What is the normally accepted fetal heart rate range?

110-160 bpm The standard acceptable fetal heart rate baseline is the range of 110-160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation. If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.

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

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

A client is now in the second stage of labor. While doing the assessment, the nurse would gather what data at this time?

contraction pattern every 15 minutes Assess the contraction pattern every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity).

A client is being admitted to labor and birth. When admitting an obstetric client in early labor, the first intervention by the nurse is:

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

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

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

A nursing student is learning about intermittent fetal heart rate monitoring during labor. The student correctly chooses which of the following as used routinely for this procedure? (Select all that apply.)

Doppler fetoscope fetal monitor Intermittent fetal heart rate ascultation uses fetoscope, Doppler, or fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions.

A client is in the active phase of labor. She is a low-risk client. The nurse evaluates the fetal monitor strip at 10:00 a.m. Moderate variability is present. The FHR is in the 130s with occasional accelerations, no decelerations. At what time does the nurse need to reevaluate the FHR?

10:30 a.m. Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives narcotics or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.

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

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

contraction pattern every 15 minutes

Assess the contraction pattern every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity).

The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded, distended, and nontender. What intervention should the nurse take next?

Check the chart for the last void. The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be taken care of by the nurse. The client 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.

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage the client's fundus. The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

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 the nurse do first?

Help the woman change positions. 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 client on her side may increase the work of breathing. Pharmacological interventions are premature.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips. For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-pace breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every three breaths is not recommended in any of the three levels of patterned breathing.

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?

Initiate the technique only when the client is in active labor. The recommendation for initiating hydrotherapy is that women be in active labor (>5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. The woman's membranes can be intact or ruptured.

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

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

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?

To prevent supine hypotension syndrome The term "rhythm strip testing" means assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, help a woman into a semi-Fowler's position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test. Placing her in this position does not decrease the heart rate of the fetus. It is not done to aid the woman as she pushes in labor, as she is not in labor yet. It is not done to prevent her from falling out of bed.

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

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

The expected fetal heart rate response in an active fetus is:

acceleration of at least 15 bpm for 15 seconds. 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 phase of the contraction?

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

administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.

A client is in the first stage of labor, latent phase. Her membranes are intact, and her contractions are mild. Considering the client's condition and phase of labor, the nurse knows that which aid will facilitate labor?

ambulation ad lib To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

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

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

Which intervention has been demonstrated to reduce the release of catecholamines and anxiety, and has resulted in better birth outcomes for women?

continuous labor support Continuous labor support has been demonstrated to result in better labor outcomes in the current research. Continuous labor support is defined as caring for the labor patient by a nurse, doula, or primary support person who does not leave the client. Massage therapy is effective in that it engages gate control. Pharmacological interventions are useful but pose potential side effects to the mother and fetus. Hypnosis is less well understood.

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

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

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:

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

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

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

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?

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

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

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

A pregnant client in her 32nd week of gestation has been admitted to a health care center reporting decreased fetal movement. What should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?

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

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor. The earlier baseline FHR was 140. The FHR now is 168. The nurse knows that which factors can affect changes in the FHR? Select all that apply.

fetal movement fetal distress maternal fever An increase in the FHR from baseline can mean that there is some type of fetal distress. This can happen with a maternal fever also. Narcotics may affect the heart rate variability but not the baseline FHR. Fetal movement can cause an increase in FHR, and utero-placental insufficiency can cause late decelerations in the FHR.

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

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

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

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

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant. 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.

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

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

A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?

taking her blood pressure and determining whether clonus or edema is present In advanced labor the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

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

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

While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:

uteroplacental insufficiency. 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.