Intrapartum

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

1. The nurse would expect the woman to be 2 cm dilated.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior position (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis.

Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. 11. What Apgar score will be assigned to the baby? 12. What are the priority nursing measures for the infant in relation to: a. Respiration b. Temperature regulation

11.The 1-minute Apgar score will be 9, with 1 point deducted for the baby's bluish hands and feet. 12. Suction to remove excess secretions; position on one side on a flat surface. b. Dry the baby quickly, particularly the head; place in a prewarmed radiant warmer Skin to-skin contact with a parent. Use a cap on the baby's dry head to reduce heat loss from that area when not in the radiant warmer.

Erin is now in the fourth stage of labor. She and her husband are getting acquainted with their baby, Derrick. 13. What time period does the fourth stage involve? 14. What nursing assessments are needed to observe for a hemorrhage? 15. What are appropriate pain relief methods during the fourth stage?

13. The first 1 to 4 hours after the placenta delivers is the fourth stage of labor. 14. Firmness, height, and position of the uterine fundus; vital signs; amount of lochia. Observing and intervening for a full bladder helps prevent hemorrhage caused by the bladder's interference with uterine contraction. 15. Cold packs to the perineal area; analgesics; a warm blanket to limit the common postbirth chill

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate

2 1. Although this client is light-headed, her problem is unlikely related to her blood pressure. 2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. 3. It is unnecessary for this client to be moved to her side. 4. The baby is not in jeopardy at this time.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2 1. This client has probably moved into the second stage of labor. Providing a bedpan is not the first action. 2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor. 3. It is too early to notify the physician. 4. It is too early to advise the mother to push

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2 Once the cervix begins to dilate, a client is in true labor.

A G1 P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication? 1. Seconal (secobarbital). 2. Vistaril (hydroxyzine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen)

2 Vistaril can be used as an analgesic potentiator.

MATH The physician writes the following order for a newly admitted client in labor: Begin a 1000 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Please calculate the drip rate to the nearest whole. _______ gtt/min

25 gtt/min Formula for drip rate calculations: volume in mL × drop factor time in minutes 150 mL/60 min × 10 gtt/mL = 150/6 150/6 = 25 gtt/min

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period

4 The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 g/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

4 is the answer 1. Fetal oxygen saturation levels are well below those seen in extrauterine life—approximately 50% to 75%. 2. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 g/dL. 3. This fetal glucose level is indicative of maternal hyperglycemia. 4. This fetal pH value is within normal limits.

The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetal heart rate is 135 to 145 beats per minute (bpm), and it accelerates when the fetus moves. Amniotic fluid is light green with small white flecks in it. The vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis. 4. What stage (and phase, if applicable) of labor is Erin in? 5. How should the fetal heart rate be interpreted? 6. Is the amniotic fluid normal? 7. What is the fetal presentation and position?

4.Active phase of first stage labor 5. The FHR is normal for a term fetus, and it is reassuring that the FHR accelerates with fetal movement. 6. Except for the greenish color, the amniotic fluid is normal. The amniotic fluid is green because the fetus passed meconium before birth. 7. Cephalic; right occiput posterior (ROP)

After 4 hours of labor in the birth center, Erin's cervix is completely dilated and effaced, and the fetal station is 11. Erin feels the need to push during some contractions. 9. What is the safest way to advise Erin to push? 10. When should Erin be positioned for birth?

9.Erin should avoid prolonged breath holding. She can be taught to take a deep breath and exhale it, then take another deep breath and push for 4 to 6 seconds at a time while exhaling. A final breath at the end of the contraction helps her relax. 10. The exact time to position Erin for birth will depend on how fast she has labored thus far. In general, a woman having her first baby is positioned for the birth when the fetal head crowns and remains visible between contractions.

Station of + 1 means that the: a. maternal cervix is open by 1 cm. b. mother's ischial spines project into her pelvis by 1 cm. c. fetus is unlikely to be born vaginally because the pelvis is small. d. fetal presenting part is 1 cm below the mother's ischial spine.

A

When palpating labor contractions, the nurse should: a. use the palm of one hand while palpating the lower uterus. b. avoid palpating during the period of maximum intensity. c. place the fingertips over the fundus of the uterus. d. limit palpations to three consecutive contractions.

A

Bloody show differs from active vaginal bleeding in that bloody show: a. quickly clots on the perineal pad. b. is dark red and mixed with mucus. c. freely flows from the vagina during vaginal ex amination. d. decreases in quantity as labor progresses

D

When performing the fourth Leopold's maneuver, the nurse determines that the cephalic prominence is on the same side as the fetal back. How should this assessment be interpreted? a. The fetus is in a breech position with the head extended. b. The fetus is in a face presentation with the head extended. c. The fetus is in a transverse lie presentation with the face toward the mother's back. d. The fetus is in a cephalic presentation with the head well flexed.

D

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

Hypotension is a very common side effect of regional anesthesia.

Erin is an 18-year-old primigravida who calls the intrapartum unit because she thinks she may be in labor. 1. What information should the nurse obtain to help determine whether Erin is in true labor? The nurse decides that Erin may be in true labor and tells her to come to the birth center. On arrival, Erin says she thinks her "water broke." 2. What is the priority nursing care at this time? 3. What tests might the nurse use to verify that Erin's membranes have indeed ruptured?

Regular contractions that have increased in duration, intensity, and frequency suggest true labor. Irregular contractions and those that do not intensify suggest false labor. In addition, discomfort is usually felt in her back or sweeping around to her lower abdomen. Erin should be instructed to come to the birth center if she thinks her membranes may have ruptured, even if she is not having 2. Priorities are to (a) assess the fetal heart rate and the color, odor, and character of the amniotic fluid; (b) assess Erin's vital signs; and (c) determine the nearness to birth by evaluating contractions and cervical dilation. 3. Tests Either the nitrazine paper or the fern test or both may be used to evaluate whether the membranes have ruptured.

MATH: The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? Calculate to the nearest hundredth

0.25 mL Formula for calculating the volume of medication to be administered: Known dosage : known value = desired dosage : desired volume 2 mg : 1 mL = 0.5 mg : x mL 2 mg x = 0.5 mg x = 0.25 mL

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous

1

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

2

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2 The woman is in early labor. There is no need for her to be hospitalized at this time.

Which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the feartension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3 1. Childbirth educators are not concerned with the possible verbalizations that laboring women might make. 2. Breathing exercises can be quite tiring. Simply being in labor is tiring. The goal of childbirth education, however, is not related to minimizing the energy demands of labor. 3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle. 4. Although childbirth educators discuss maternal-newborn bonding, it is not a priority goal of childbirth education classes.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3 Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.

It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula

4 A fetus in a scapular presentation is in a horizontal lie

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 3. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconiumstained fluid. The client needs to be assessed. 5. The latent phase of labor can last up to a full day. In addition, Braxton Hicks' contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask

1 1. This is the correct response. A fetal heart rate of 152 is normal. 2. This woman is in early labor. The fetal heart does not need to be assessed every 5 minutes. 3. The rate is normal. There is no need to report the rate to the health care practitioner. 4. The rate is normal. There is no need to institute emergency measures.

The abbreviation LOA means that the fetal occiput is: a. on the examiner's left and in the front of the pelvis. b. in the left front part of the mother's pelvis. c. anterior to the fetal breech. d. lower than the fetal breech.

B

The nurse notes the following contraction pattern: Beginning of Contractions End of Contractions 11:15:00 11:15:40 11:20:00 11:20:45 11:24:00 11:24:50 11:28:30 11:29:10 11:33:00 11:33:35 Choose the correct documentation for the pattern. a. Contractions every 4 to 5 minutes; duration 35 to 50 seconds b. Contractions every 5 minutes; duration 35 to 40 seconds c. Contractions every 3 to 5 minutes; duration 30 to 50 seconds d. Contractions every 3 to 4 minutes; duration 30 to 40 seconds

B