Intrapartum
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the client at this time? 1 The cervix dilates and becomes effaced in true labor. 2 Bloody show is the first sign of true labor. 3 The membranes rupture at the beginning of true labor. 4 Fetal movements lessen and become weaker in true labor.
Answer: 1 The cervix dilates and becomes effaced in true labor. The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional
Answer: 1 First The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
A client at 42 weeks' gestation is scheduled for induction of labor. The nurse begins the induction with a piggyback infusion of 15 units of oxytocin. Which clinical finding requires the nurse to discontinue the oxytocin infusion? 1 Contractions that occur every 3 minutes and lasting 60 seconds 2 Elevation of blood pressure from 110/70 to 135/85 mm Hg during the last 30 minutes 3 Rupture of membranes with amniotic fluid that contains threads of blood and mucus 4 Several late fetal heart rate decelerations that return to baseline after the contraction is over
Answer: 4 Several late fetal heart rate decelerations that return to baseline after the contraction is over Late decelerations suggest uteroplacental insufficiency, which is an indication that the oxytocin infusion should be stopped. Continuing the infusion may compromise the status of the fetus. Contractions that occur every 3 minutes and last 60 seconds are within acceptable parameters; they require continued monitoring, and the infusion of oxytocin may be continued. An increase in blood pressure from 110/70 to 135/85 mm Hg during the past 30 minutes or rupture of the membranes requires continued monitoring, but does not make it necessary for the infusion of oxytocin to be stopped.
A nurse assesses the frequency of a client's contractions by timing them from the beginning of a contraction until when? 1 The uterus starts to relax 2 The end of a second contraction 3 The uterus has relaxed completely 4 The beginning of the next contraction
Answer: 4 The beginning of the next contraction Timing until the beginning of the next contraction is the accepted way of determining the frequency of contractions. The time between beginning of a contraction and when the uterus starts to relax is not an indication of the duration of a contraction. The time from the beginning of a contraction to the end of a second one does not reflect the frequency of contractions. Complete relaxation of the uterus indicates the end of a contraction, but measuring the time from the beginning of the contraction until relaxation occurs is not the accepted way of timing the frequency of contractions.
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question? 1 Usually fluctuate in length 2 Continuous, without relaxation 3 Related to time of membrane rupture 4 Accompanied by progressive cervical dilation
Answer: 4 Accompanied by progressive cervical dilation Progressive cervical dilation is the only positive sign of true labor; the cervix dilates in response to regular, coordinated uterine contractions. The contractions of true labor increase in length and intensity. A continuous contraction may have an adverse effect on the fetus; immediate intervention is required. The membranes may rupture before contractions begin; more frequently they rupture after true labor is established.
The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw-colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks
Answer: 2 Straw-colored, clear, and containing little white specks By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.
A woman in labor hears the primary healthcare provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond? 1 "A vaginal birth is possible." 2 "We're anticipating a cesarean delivery." 3 "It has no relevance to the labor and birth." 4 "Labor probably will be long, and you might have back pain."
Answer: 1 "A vaginal birth is possible." A longitudinal lie means that the fetus is lying parallel to the woman's spine; therefore vaginal birth is possible. A transverse, not longitudinal, lie might indicate that vaginal birth is unlikely, and cesarean birth is anticipated. The fetal lie will influence the labor and the birth of the fetus. A longitudinal lie does not indicate that the labor will be prolonged; however, if the fetal head is in the posterior occiput position, second-stage labor may be prolonged, accompanied by back pain.
A client at 40 weeks' gestation is admitted to the birthing unit, and an amniotomy is performed to facilitate labor. Once the nurse determines that the umbilical cord has not prolapsed, what is her next action? 1 Assessing the fetal heart rate 2 Obtaining the maternal vital signs 3 Turning the client on her left side 4 Monitoring the frequency of contractions
Answer: 1 Assessing the fetal heart rate Once cord prolapse and consequent cord compression have been ruled out, it is imperative to evaluate the effect of the amniotomy on the fetus. Obtaining the maternal vital signs is not the priority; it can be done later. Although turning the client on her left side is important, fetal well-being is the priority concern. There are no data to indicate that contractions have started.
The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In which stage of labor is this client? 1 First 2 Latent 3 Second 4 Transitional
Answer: 1 First The client is in the first stage of labor because she is fully effaced but not yet completely dilated. The first stage lasts from the onset of contractions until full cervical effacement and dilation. The second stage of labor lasts from complete dilation to birth. Latent and transition are phases and not stages of labor. Latent is the first phase of the first and second stages of labor. Transition is the last of three phases occurring in the first stage of labor.
The nurse is caring for a client who has just had an amniotomy performed by the primary healthcare provider. The fetal heart rate immediately decreases from 140 to 80 beats/min. What is the priority nursing action? 1 Inspecting the vagina 2 Administering oxygen 3 Increasing the intravenous fluids 4 Placing the client in the knee-chest position
Answer: 1 Inspecting the vagina Follow the nursing process and begin with an assessment to determine possible cause for the deceleration. This is likely to be a prolapsed cord based on the recent history of an amniotomy. Inspection of the vagina is performed. A cord prolapse requires immediate removal of the presenting part from the cord. Oxygen may be administered later; however, this is not the priority. Increasing the intravenous fluids is also not the priority at this time. Placing the client in the knee-chest position is an intervention that can be implemented once it is determined that the umbilical cord is prolapsed. This position relieves pressure on the cord, which increases the flow of oxygen and nutrients to the fetus.
While caring for a client during labor, what does the nurse remember about the second stage of labor? 1 It ends at the time of birth. 2 It ends as the placenta is expelled. = 3 It begins with the transition phase of labor. 4 It begins with the onset of strong contractions.
Answer: 1 It ends at the time of birth. The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
The electronic fetal monitor displays contractions every 2 minutes and lasting 95 seconds. What is the nurse's highest priority intervention at this time? 1 Stop the oxytocin (Pitocin) infusion. 2 Administer oxygen at 8 to 10 L/min. 3 Increase the main line fluid delivery rate to 150 mL/hr. 4 Prepare the client for insertion of an intrauterine pressure catheter.
Answer: 1 Stop the oxytocin (Pitocin) infusion. The contraction pattern indicates hyperstimulation of the uterus. Stopping the oxytocin infusion permits relaxation of the uterus and perfusion of the placenta. Oxygen cannot reach the placenta until the uterus is relaxed, so administering oxygen will not help. Increasing the rate of delivery of the main line fluid does not affect hyperstimulation of the uterus. Insertion of an intrauterine pressure catheter will only provide measurement of the internal uterine pressure and will not affect uterine contractions.
A client is admitted to the birthing unit because fluid is leaking from her vagina. She is unsure whether her "bag of water" has broken. What should the nurse do to help determine whether the fluid is amniotic fluid? 1 Test the fluid with Nitrazine paper. 2 Inspect the fluid for its characteristics. 3 Assess the fluid for the presence of protein. 4 Send the fluid to the laboratory for analysis.
Answer: 1 Test the fluid with Nitrazine paper. Amniotic fluid is slightly alkaline, and urine is acidic; when moistened with amniotic fluid, Nitrazine will turn dark blue, indicating an alkaline substance. Inspecting the fluid is a subjective assessment and may be inaccurate. Protein is not a discriminating factor, because it may be present in urine and amniotic fluid, especially in the urine, if the client shows signs of preeclampsia. The fluid need not be sent to the laboratory; it can be tested immediately for alkalinity with Nitrazine paper.
A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and dilated 3 cm. The fetal head is at +1 station. In which area of the client's pelvis is the fetal occiput? 1 Not yet engaged 2 Below the ischial spines 3 Entering the pelvic inlet 4 Visible at the vaginal opening
Answer: 2 Below the ischial spines A station of +1 indicates that the fetal head is 1 cm below the ischial spines. The head is now past the points of engagement, the ischial spines. When the head is entering the pelvic inlet, it is said to be at 0 station. The head must be at +3 to +4 station to be visible at the vaginal opening.
After an uneventful pregnancy a client at term arrives at the birthing unit. The nurse determines that her contractions are 10 minutes apart and that her cervix is dilated 2 cm. What stage of labor should the nurse document in the client's medical record? 1 Second stage 2 Latent first stage 3 Active first stage 4 Transition stage
Answer: 2 Latent first stage Regular contractions occurring 10 minutes apart with a cervix dilated 2 cm indicate that the client is in the latent phase of the first stage of labor. The second stage of labor begins with full dilation and ends with expulsion of the fetus. Contractions occur more regularly and more frequently and the cervix is more dilated in the active stage of labor. Contractions are intense and occur every 1 to 2 minutes in the transition phase of the first stage of labor.
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. What is the likely cause of these late decelerations? 1 Imminent vaginal birth 2 Uteroplacental insufficiency 3 Pattern of nonprogressive labor 4 Reassuring response to contractions
Answer: 2 Uteroplacental insufficiency Late decelerations are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both. The imminence of birth cannot be determined from fetal heart rate decelerations, only from cervical dilation. Birth occurs after the cervix has dilated to 10 cm and the fetus has passed through the birth canal. Nonprogressive labor cannot be determined from fetal heart rate decelerations, only from cervical dilation. Late decelerations are not expected, are not reassuring, and must not be ignored.
A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show present. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond? 1 "I can't make a decision on that; I'll have to ask your primary healthcare provider." 2 "Please stay in bed; walking could interfere with effective uterine contractions." 3 "It's all right for you to walk as long as you feel comfortable and your membranes are intact." 4 "You may sit in a chair, because your contractions cannot be timed when you walk and I won't be able to listen to the baby's heart."
Answer: 3 "It's all right for you to walk as long as you feel comfortable and your membranes are intact." Contractions become stronger and more regular when the woman is standing; also, as the woman walks, the diameter of the pelvic inlet increases, allowing easier entrance of the head into the pelvis. Judging from the information gleaned during the admitting assessment the nurse is qualified to make this decision. The contractions of true labor are enhanced when the mother walks. Timing of contractions and Doppler auscultation of the fetal heart rate may be continued even if the client chooses to walk.
What is the optimal nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1 Document the fetal heart rate every 5 minutes. 2 Call the anesthesia department to alert the staff there of an imminent birth. 3 Assist the client's coach in helping her with the use of breathing techniques. 4 Suggest that the client accept the as-needed (PRN) medication for pain that has been prescribed.
Answer: 3 Assist the client's coach in helping her with the use of breathing techniques. The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal heart rate every 5 minutes until the second stage of labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? 1 Face 2 Brow 3 Breech 4 Shoulder
Answer: 3 Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.
The four essential components of labor are passenger, powers, passageway, and position. Passageway refers to the bony pelvis. Which type of pelvis is considered the most favorable for a vaginal delivery? 1 Android 2 Anthropoid 3 Gynecoid 4 Platypelloid
Answer: 3 Gynecoid A gynecoid pelvis is considered the most favorable for a vaginal birth because the inlet allows the fetus room to easily pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus would have difficulty passing through this shape of pelvis. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.
A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication should the nurse anticipate when assessing the character of the client's amniotic fluid? 1 Cord prolapse 2 Placenta previa 3 Maternal sepsis 4 Abruptio placentae
Answer: 3 Maternal sepsis Prolonged rupture of membranes of more than 18 hours increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be? 1 Teach the client how to push with each contraction. 2 Encourage the client to perform patterned, paced breathing. 3 Provide the client with comfort measures used for women in labor. 4 Prepare to have the client's blood typed and crossmatched in the event of the need for a transfusion.
Answer: 3 Provide the client with comfort measures used for women in labor. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed.
The nurse is caring for a client who is in the first stage of labor. The fetal heart rate monitor displays an irregular baseline that was in the 150s and is now in the 130s with variability. What is the priority nursing intervention? 1 Administering oxygen 2 Notifying the primary healthcare provider 3 Changing the client's position 4 Continuing to monitor the client
Answer: 4 Continuing to monitor the client This is an expected occurrence caused by the interplay of the sympathetic and parasympathetic nervous systems. Because this is an expected response, there is no need to administer oxygen, notify the primary healthcare provider, or change the client's position.
A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? 1 The fetus has a neural tube defect 2 Fetal well-being is compromised 3 Intrauterine infection has developed 4 Meconium is being expelled with contractions
Answer: 4 Meconium is being expelled with contractions In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluid is not a sign of a neural tube defect, regardless of presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate signs of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection.
Physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. Where should the nurse place the stethoscope to best locate the fetal heart tones?
Answer: A When the fetus's back is on the right side of the mother and the fetal sacrum is in the lower portion of the fundus, the fetus is in the right sacrum anterior (RSA) position and the fetal heart can be heard in the right upper quadrant. Location b is appropriate when the fetus is in the right occipital posterior (ROP) position. Location c is appropriate when the fetus is in the left sacrum anterior (LSA) position. Location d is appropriate when the fetus is in the left occipital anterior (LOA) position.