Chapter 16: Labor and Delivery: PREPU

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? 1 Nothing. Normal time for stage three is 5 to 30 minutes. 2 Notify the primary care provider of the problem. 3 Increase the IV tocolytic to help in expulsion of the placenta. 4 Do a vaginal exam to see if the placenta is stuck in the birth canal.

1

Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first? 1 Place the patient supine. 2 Raise the head of the bed. 3 Ask the patient to take deep breaths. 4 Turn onto the left side or raise the legs.

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Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply. 1 Increase in bloody show 2 The woman is more quiet and introverted 3 The client states an urge to push 3 Irritability and restlessness may occur 4 The client may begin to cry 5 Hyperventilation may occur

All except for 2

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: 1 lightening. 2 start of labor. 3 placenta previa. 4 rupture of the membranes.

1

A client has just received combined spinal epidural. Which nursing assessment should be performed first? 1 Assess vital signs. 2 Assess pain level using a pain scale. 3 Assess for progress in labor. 4 Assess for spontaneous rupture of membranes. 5 Assess for fetal tachycardia.

1

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? 1 "The analgesia will limit your ability to be out of bed without assistance." 2 "The analgesia will block pain sensation and limit your ability to push." 3 "The analgesia will reduce the sensation of pain for a limited period of time." 4 "The analgesia will allow for a pain-free birth experience."

3

During which time is the nurse correct to document the end of the third stage of labor? 1 Following fetal birth 2 When pushing begins 3 At the time of placental delivery 4 When the mother is moved to the postpartum unit

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When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture? 1 Meconium-stained amniotic fluid 2 Fetus presenting in an LOA position 3 Maternal pulse of 90 to 95 beats/min 4 Blood-tinged vaginal discharge at full dilation

1

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: 1 7.15 or less. 2 7.25 or more. 3 7.20. 4 7.21.

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

The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? 1 Administer oxygen. 2 Increase her IV fluids. 3 Change the position of the client. 4 Notify the primary care provider.

3 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.

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? 1 "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." 2 "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." 3 "If you end up having a cesarean, the epidural can be used for anesthesia during surgery." 4 "You have no trouble walking around and using the bathroom after you receive the epidural."

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Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? 1 The father's coaching role may be disrupted at times. 2 The infant may show increased drowsiness. 3 The mother may have continued memory loss postpartum. 4 The mother may have difficulty working effectively with contractions.

4

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? 1 Administration of 500 mL of IV Ringer's lactate 2 Administration of 1000 mL of IV glucose solution 3 Move the woman into a supine position 4 Administration of aspirin

1

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? 1 transition phase 2 latent phase 3 active phase 4 early phase

1

A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: 1 cranial bones overlapping at the suture lines. 2 extreme pressure in the vaginal vault. 3 a congenital defect. 4 prolonged labor.

1

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? 1 sutures 2 fontanelles 3 frontal bones 4 biparietal diameter

1

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 explanation should the nurse give? 1 "It distracts your brain from the sensations of pain." 2 "It causes the release of endorphins." 3 "It blocks the transmission of nerve messages of pain at the receptors." 4 "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

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A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? 1 increased risk of infection 2 potential rapid birth of fetus 3 potential placenta previa 4 increased risk of breech presentation

1

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements? 1 "Transverse lie is the same as when the fetal buttocks present to the birth canal." 2 "Transverse lie is the same as when the shoulder presents to the birth canal." 3 "Breech presentation is when the fetal buttocks present to the birth canal." 4 "In most pregnancies at term the fetus presents head down."

1

A primigravidia client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? 1 "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." 2 "This is not normal unless you are in active labor; come to the hospital and be checked." 3 "That is something we expect with a second or third baby, but because it is your first, you need to be checked." 4 "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

1

A woman, who has been in labor for a few hours, is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat? 1 "You could have some hard candy to suck on." 2 "What would you like to eat?" 3 "You can have a protein supplement." 4 "I can get you something soft and easy to digest, like pudding."

1

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? 1 reports of severe back pain 2 lack of cervical dilation past 2 cm 3 fetal buttocks as the presenting part 4 contractions most forceful in the middle of uterus rather than the fundus

1

The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording? 1 Acceleration of at least 15 bpm for 15 seconds 2 Increase in variability by 27 bpm 3 Deceleration followed by acceleration of 15 bpm 4 Decrease in variability for 15 seconds

1

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? 1 external electronic fetal monitoring 2 fetal blood pH 3 fetal oxygen saturation 4 fetal position

1

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency? 1 every 15 minutes 2 every 10 minutes 3 every 5 minutes 4 every 20 minutes

1

Which statement is true regarding analgesia versus anesthesia? 1 Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. 2 Decreased FHR variability is a common side effect when regional anesthesia is used. 3 Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. 4 Hypotension is the most common side effect when systemic analgesia is used.

1

A client 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 out of 10 with each contraction. What should the nurse do first? 1 Assess for labor progression. 2 Prepare the client for an epidural. 3 Assist the client in ambulating to the bathroom. 4 Instruct the client to do slow-paced breathing.

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

A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? 1 implementing measures for a vaginal birth 2 preparing the client for a cesarean birth 3 assisting with artificial rupture of the membranes 4 instituting continuous internal fetal monitoring

1 The fetal presentation and position is left occiput anterior position or LOA, which is the most common and most favorable fetal position for birth. LOA along with right occiput anterior position are optimal positions for vaginal birth. Therefore the nurse should implement measures for a vaginal birth.

Which nursing action is a priority when the fetus is at the +4 station? 1 Have a blue bulb suction and an infant warmer ready 2 Have a tocometer and a patient gown ready 3 Provide lubricating jelly and an internal monitor 4 Prepare for an immediate cesarean section

1 At the station +4, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation, the nurse will have a lubricant and possibly an internal monitor per health care provider orders.

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. 1 latent 2 pre-labor 3 active 4 transition 5 inactive

1, 3, 4

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? 1 The contraction pains are 2 minutes apart and 1 minute in duration. 2 The client reports back pain, and the cervix is effacing and dilating. 3 The contraction pains have been present for 5 hours, and the patterns are regular. 4 After walking for an hour, the contractions have not fully subsided.

2

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: 1 "Effleurage is the pattern for cleaning the perineum before birth." 2 "Effleurage is light abdominal massage used to displace pain." 3 "Effleurage is the effect of a full bladder on fetal descent." 4 "Effleurage is massaging the perineum as the fetal enlarges the vaginal opening."

2

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? 1 Immersing the client in warm water in a pool or hot tub 2 Practicing effleurage on the abdomen 3 Administering a sedative such as secobarbital or pentobarbital 4 Administering an opioid such as meperidine or fentanyl

2

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? 1 notify the health care provider 2 reposition the client on either side 3 palpate for bladder fullness 4 do nothing, this is benign

2

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? 1 Massage therapy 2 Continuous labor support 3 Pharmacologic pain management 4 Prenatal classes

2

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? 1 crowning 2 effacement 3 dilatation 4 molding

2

A home care client at 30 weeks' gestation calls the home care nurse asking her to come over for an immediate visit. The nurse explains that she is unable. The client states that she is experiencing contractions and bleeding. What is the priority response by the nurse. 1 "I will cancel my appointment and be right over." 2 "Call 911." 3 "How far apart are your contractions?" 4 "I will contact the primary care provider."

2 Signs of preterm labor. call 911 to transport to the hospital

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? 1 "My contractions are really intense now." 2 "My lips and fingers are tingling." 3 "My mouth and lips are so dry." 4 "I feel burning in my perineum."

2 When the client reports that her lips and fingers are tinging, the nurse is correct to understand that she is hyperventilating. When the client reports that her lips and fingers are tinging, the nurse is correct to understand that she is hyperventilating. To correct hyperventilation, the nurse instructs the client to slow the breathing. A paper bag or cupped hands is the correct nursing action. All of the other statements are normal for the client in the transition phase of labor. The nurse would moisten the client's lips or provide a lip balm for dry mouth or lips.

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client? 1 Braxton Hicks contractions are not strong enough during first pregnancy. 2 Contractions are stronger during the first pregnancy than the second. 3 The cervix takes around 12 to 16 hours to dilate during first pregnancy. 4 Spontaneous rupture of membranes occurs during first pregnancy.

3

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? 1 Tell the woman to stay home until her membranes rupture. 2 Emphasize that food and fluid should stop or be light. 3 Ask the woman to describe why she believes that she is in labor. 4 Arrange for the woman to come to the hospital for labor evaluation.

3

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? 1 Anxiety will increase blood pressure, increasing risk with an epidural. 2 Decreased anxiety will increase trust in the nurse. 3 Anxiety can slow down labor and decrease oxygen to the fetus. 4 Increased anxiety will increase the risk for needing anesthesia.

3

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? 1 every 5 minutes 2 every 10 minutes 3 every 15 minutes 4 every 20 minutes

3

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? 1 Risk factors 2 Maternal status 3 Fetal status 4 Maternal obstetrical history

3

The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which? 1 The client is fully effaced. 2 The fetus is floating high in the pelvis. 3 The fetus is in the true pelvis and engaged. 4 The fetus has descended down the birth canal.

3

The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process? 1 Early stage labor 2 Before dilation only 3 Just before birth 4 Just after birth

3

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? 1 occiput 2 face 3 buttocks 4 shoulder

3

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? 1 application of vibroacoustic stimulation 2 tactile stimulation 3 administration of oxygen by mask 4 fetal scalp stimulation

3 The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus.

A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor? 1 contractions every 5 minutes, cervical dilation 3 cm 2 contractions every 3 minutes, cervical dilation 5 cm 3 contractions every 2½ minutes, cervical dilation 7 cm 4 contractions every 1 minute, cervical dilation 9 cm

4

The client may spend the latent phase of the first stage of labor at home unless which occurs? 1 The client passes the bloody show 2 The contractions vary in length and intensity 3 The client begins back labor 4 The client experiences a rupture of membranes

4

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? 1 Emotions are calm and happy. 2 Frequency of contractions are 5 to 6 minutes. 3 Fetus is at -1 station. 4 The urge to push occurs.

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