Intrapartum- Pearson
Absolute cephalopelvic disproportion Forceps is contraindicated in a patient with absolute cephalopelvic disproportion. Forceps in this situation may cause fetal or maternal trauma. A gestation of 39 weeks, a fully dilated cervix, and ruptured membranes are not specific contraindications for the use of forceps.
A laboring patient has been pushing for 2 hours. The healthcare provider has discussed using forceps to assist with the delivery. Which factor should the nurse recognize that would contraindicate the use of forceps? Fully dilated cervix Ruptured membranes Absolute cephalopelvic disproportion Gestation of 39 weeks
"The bloody show is a sign that labor will begin." The statement that best describes bloody show is that it is a sign that labor will begin. Labor usually begins within 24-48 hours of noting the bloody show. Bloody show does not occur after the amniotic sac has ruptured, does not necessarily indicate that delivery is imminent, and is not an abnormal finding.
A patient experiencing contractions states that she noticed "bloody show" before coming to the hospital. The patient asks the nurse, "Is that bleeding normal since my contractions are 5 minutes apart?" Which information should the nurse include the response? "The bloody show occurs after the amniotic sac has ruptured." "The bloody show is an abnormal finding in early labor." "The bloody show is a sign that labor will begin." "The bloody show indicates that delivery is imminent."
Uterine contractions Oxytocin is a uterotonic used for induction of labor or control of a postpartum hemorrhage. Oxytocin does not decrease pain, rupture membranes, or decrease anxiety.
A patient has been prescribed oxytocin for an induction of labor. Which effect should the nurse anticipate after administering the prescribed medication? Ruptured membranes Decreased pain Decreased anxiety Uterine contractions
Trickling vaginal bleeding As the placenta separates from the uterine wall, the uterus becomes globular in shape, rises above the umbilicus, and a vaginal trickling of blood may result. The umbilical cord does not shorten as the placenta is delivered. After the delivery of the placenta, the uterus contracts, resulting in a decrease in bleeding. A boggy uterus indicates a soft uterus with no contractions.
A patient has completed the second stage of labor. Which assessment finding should the nurse anticipate prior to placental delivery? Shortening of the umbilical cord Change in the uterus to a disk shape Boggy uterus Trickling vaginal bleeding
Assisting in the delivery of the placenta Delivery of the placenta usually takes place within 30 minutes of birth. Signs that the placenta is about to be delivered include a gush of blood and protrusion of the umbilical cord from the vagina. The nurse's priority responsibility at this time is to assist with the delivery of the placenta. Perineal lacerations do not generally cause a gush of blood. The umbilical cord should not be forcibly pulled, because this action may result in a uterine inversion. The vaginal bleeding will decrease when the placenta is delivered.
Fifteen minutes after a patient delivered vaginally the nurse notes that there is a "gush" of blood and the umbilical cord protrudes from the vagina. Which is the nursing priority based on the assessment findings? Pulling on the umbilical cord to remove it Assisting the healthcare provider in stopping the vaginal bleeding Inspecting the perineum for lacerations Assisting in the delivery of the placenta
The patient with fibroids in the lower uterine segment The patient on the unit at greatest risk for a cesarean birth is the patient with the fibroids in the lower uterine segment. The fibroids may result in a mechanical obstruction and interfere with the uterine muscle contractions. A patient with bipolar disorder or gestational diabetes is not at risk for a cesarean section unless complications from the diagnosis interfere with maternal and fetal well-being. There is no evidence that a cesarean section reduces the maternal fetal transmission of hepatitis C.
The charge nurse is reviewing the labor and delivery census. Which patient on the unit poses the greatest risk for requiring a cesarean birth? The patient with hepatitis C The patient with bipolar disorder The patient with fibroids in the lower uterine segment The patient with gestational diabetes
Pant-blow breathing When using abdominal breathing, pant-blow breathing can be initiated to prevent hyperventilation. Slow-paced breathing and modified-paced breathing may not be effective in slowing down the patient's breathing to prevent hyperventilation. A cleansing breath is taken at the beginning of modified-paced breathing.
The nurse is coaching a patient in labor who is using abdominal breathing. The nurse notes that the patient is beginning to breathe too rapidly. Which method of breathing is the most effective at preventing the patient from hyperventilating? Pant-blow breathing A cleansing breath Modified-paced breathing Slow-paced breathing
Absolute cephalopelvic disproportion Forceps is contraindicated in a patient with absolute cephalopelvic disproportion. Forceps in this situation may cause fetal or maternal trauma. A gestation of 39 weeks, a fully dilated cervix, and ruptured membranes are not specific contraindications for the use of forceps.
A laboring patient has been pushing for 2 hours. The healthcare provider has discussed using forceps to assist with the delivery. Which factor should the nurse recognize that would contraindicate the use of forceps? Fully dilated cervix Ruptured membranes Gestation of 39 weeks Absolute cephalopelvic disproportion
Decreasing the oxytocin rate Hypertonic contractions may be caused by oxytocin administration. The priority intervention is to decrease the oxytocin. If the fetal heart rate tracing is nonreassuring, the oxytocin should be discontinued and the healthcare provider notified. It is not appropriate to ask the patient to bear down or to ambulate to the bathroom or in the hallway.
A laboring patient is exhibiting a hypertonic uterine contraction pattern. Which is the priority collaborative intervention the nurse should implement? Having the patient ambulate in the hall Asking the patient to bear down Assisting the patient to the restroom to void Decreasing the oxytocin rate
Calmly providing reassurance and keeping the patient apprised of their progress During the second stage of labor, the woman may have increased anxiety and feelings of losing control that will require extra reassurance and support. The most therapeutic action for the patient is to calmly provide reassurance and keep them apprised of their progress. It is not necessary to prepare the operating room; the healthcare provider will make the decision whether to perform a cesarean birth. Offering the patient ice chips and telling them that the baby will come when it is ready is not a therapeutic response for anxiety. Antianxiety medication is not appropriate for a laboring patient.
A patient has been in the second stage of labor for 2 hours. The patient begins crying and states, "I am so tired. Can I just have a cesarean birth? I cannot do this anymore." Which action by the nurse provides the most therapeutic response? Offering the patient an antianxiety medication to help calm them down Offering the patient ice chips and telling them the that baby will come when it is ready Preparing the operating room and calling the anesthesiologist for an epidural Calmly providing reassurance and keeping the patient apprised of their progress
External fetal monitoring The method of fetal monitoring for a patient with an epidural and oxytocin augmentation during the second stage of labor is continuous external fetal monitoring. Internal fetal monitoring is unnecessary unless the nurse is unable to obtain a continuous tracing or there is suspected fetal compromise. A Doppler does not provide continuous monitoring of the fetal heart rate and uterine activity. An ultrasound is inappropriate to use to monitor a patient in labor.
A patient in the second stage of labor has an epidural for pain control and is augmented with oxytocin. Which method of fetal monitoring should the nurse utilize? Ultrasound External fetal monitoring Internal fetal monitoring Doppler
Squatting The mother may assume any position for pushing that is comfortable for them and reasonably accessible to the healthcare provider. Squatting is one such position. Standing in the shower is not accessible for examination of progress and fetal assessment. The dorsal recumbent and lithotomy positions are typically very uncomfortable and do not promote uteroplacental circulation.
A patient in the second stage of labor states, "I feel like I have to push." Which position should the nurse encourage the patient to assume? Squatting Standing in the shower Dorsal recumbent Lithotomy
"Oxytocin stimulates uterine contractions." The most accurate statement made is, "Oxytocin stimulates uterine contractions." Oxytocin is a potent uterine stimulant and is frequently used as an agent to induce or augment labor in term pregnancies or when delivery is necessitated. Oxytocin does not the cause relaxation of uterine muscle, gently induce labor, or provide pain relief for the laboring patient.
A patient is admitted for induction of labor. The patient asks, "What exactly does oxytocin do?" Which response by the nurse is accurate? "Oxytocin is used to ease you gently into labor." "Oxytocin stimulates uterine contractions." "Oxytocin provides pain relief during your labor." "Oxytocin helps relax the uterus."
Forceps-assisted delivery Forceps-assisted delivery increases the patient's chance of requiring a midline episiotomy. A preterm delivery, fetal occipital anterior position, or a side-lying pushing position does not place the patient at risk for requiring an episiotomy.
A patient is in the second stage of labor. The nurse should understand that which factor increases the chances of the patient requiring an episiotomy? Side-lying pushing position Preterm delivery Occipital anterior fetal position Forceps-assisted delivery
Offering encouragement and support The patient in the transition phase of labor often requires encouragement and support. The patient may experience a great deal of anxiety, irritability, self-doubt, and feel fatigued as they become acutely aware of the increasing force and intensity of the contractions. Frequent perineal cleaning, repositioning, and frequent sips of water may be appropriate nursing interventions; however, the overall most important intervention is the encouragement and support the nurse provides.
A patient with no analgesia is 8 cm, 100% effaced, +1 station. Which should the nurse consider as the priority nursing intervention? Providing frequent sips of water Encouraging repositioning Offering encouragement and support Providing frequent perineal cleansing
"Let me get you a menu, so you can choose what you would like." There is no medical indication that restricts the patient from eating a general diet. It is not necessary to start the patient on a liquid diet, notify a healthcare provider, or restrict the patient from eating based on the use of regional anesthesia in labor.
A stable patient who is in the fourth stage of labor has delivered vaginally. The patient states, "I am so hungry, can I please have something to eat?" Which response by the nurse is appropriate? "Let me get you a menu, so you can choose what you would like." "You have had regional anesthesia during labor, so we would prefer that you wait to eat." "I will check with your healthcare provider." "You can start with a liquid diet and then advance to solids."
The patient at 42 weeks of gestation with a cephalic presentation The patient who is at 42 weeks of gestation with a cephalic presentation will be scheduled for an induction of labor. The patient is at risk for placental insufficiency, which affects fetal oxygenation and nutrition. A patient at 36 weeks of gestation with a marginal placenta previa and no bleeding is not an indication for delivery; the fetus is preterm. The patient at 37 weeks of gestation with a fetal transverse lie is not a candidate for a vaginal delivery, and there is no indication to deliver the baby. The patient at 36 weeks of gestation with diabetes mellitus is not a candidate for delivery due to prematurity. Cephalic presentation with vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis.
The nurse in the clinic is reviewing a list of obstetrical patients scheduled for prenatal visits. Which clinical situation indicates that an induction of labor will need to be scheduled? The patient at 36 weeks of gestation with a marginal placenta previa scheduled for a routine visit The patient at 37 weeks of gestation with a fetal transverse lie The patient at 42 weeks of gestation with a cephalic presentation The patient at 36 weeks of gestation with diabetes mellitus
Continuing to monitor the patient The patient's assessment findings are normal for the fourth stage of labor. The priority action is to continue to monitor the patient. The patient is stable and may have a general diet at this time. It is not necessary to massage the fundus, reposition the patient on the left side, or place the bed in the Trendelenburg position.
The nurse is assessing a patient in the fourth stage of labor. The patient's BP is 110/60 mmHg and pulse is 90 beats/min. The patient's fundus is firm, midline, and between the umbilicus and symphysis pubis. Which is the priority action based on the assessment findings? Repositioning the patient onto her left side Placing the bed in the Trendelenburg position Massaging the uterine fundus Continuing to monitor the patient
The patient reports a decrease in fear and anxiety.
The nurse is caring for a laboring patient who presents with fetal malpresentation. Based on the patient's clinical presentation, the nurse formulates the nursing diagnosis of Fear related to fetal outcome. Which is an appropriate patient outcome to include in the plan of care based on the nursing diagnosis? The patient verbalizes an understanding of the labor process. The patient identifies a support person for the birth. The patient reports a decrease in fear and anxiety. The patient delivers a viable newborn.
Encouraging the patient to void every 2 hours Bladder distention can displace the uterus, inhibiting its ability to contract, which can result in excessive vaginal bleeding. The mother should be encouraged to void every 2 hours to avoid bladder distention. Palpating the fundus is part of a fundal assessment. Ambulation does not prevent bladder distention. Pouring warm water over the perineum will help stimulate micturition.
The nurse is caring for a patient in the fourth stage of labor. Which nursing intervention should be implemented to avoid maternal bladder distention? Encouraging the patient to ambulate Palpating the fundus Pouring cold water over the perineum Encouraging the patient to void every 2 hours
The baby's head is crowning. Progress in the second stage of labor is noted with crowing of the head that no longer recedes and remains visible at the vaginal introitus between contractions, meaning that birth is imminent. An increase in bloody show and rectal pressure are signs of transition in the first stage of labor. A patient who is very focused on their contractions is most likely experiencing active labor, which occurs during the first stage of labor.
The nurse is caring for a patient in the second stage of labor. Which best describes adequate progress of labor during this stage? The patient complains of increasing rectal pressure. There is an increase in bloody show. The patient appears to be very focused on their contractions. The baby's head is crowning.
Assessing the fetal heart rate every 5-15 minutes The most appropriate nursing action for the patient in the second stage of labor is the assessment of the fetal heart rate every 5-15 minutes to ensure the fetal heart rate is reassuring (normal). The maternal vital signs are assessed every 15-30 minutes during the second stage of labor. The cervix is completely dilated in the second stage of labor; therefore, it is unnecessary to assess the dilation.
The nurse is caring for a patient in the second stage of labor. Which nursing action is the most appropriate during the second stage of labor? Assessing the fetal heart rate every 30 minutes Assessing the cervical dilation every 30 minutes Assessing the fetal heart rate every 5-15 minutes Assessing the maternal vital signs hourly
100% effacement As the cervix dilates, effacement occurs. The cervical effacement that is associated with a patient in the transition phase of labor is 100% effacement. A cervix that is 0% effaced is a not effaced at all. A 30% and 50% effacement of the cervix is an expected finding in the latent and active phases of labor.
The nurse is caring for a patient in the transition phase of labor. Which cervical effacement assessment should the nurse expect? 100% effacement 50% effacement 30% effacement 0% effacement
"My husband can be present during the birth." The statement made by the patient that demonstrates an understanding of the teaching is, "My husband can be present during the birth." Providing there are no anticipated complications, the patient's partner is generally allowed to attend the birth. It is not customary to make the patient's partner wait to see the baby; the partner is encouraged to attend the birth. Generally, in a well newborn nursery only members of the healthcare team are allowed in the nursery for purposes of infection control and patient privacy. A blood transfusion is not routinely initiated during a cesarean birth. The patient may be given an antacid prior to the surgery to neutralize the acid in the stomach. An indwelling urinary catheter is inserted prior to the surgery to prevent bladder distention and injury.
The nurse is providing teaching regarding the expectations during a scheduled cesarean birth to a patient and their husband. Which patient statement demonstrates an understanding of the teaching? "I will receive a blood transfusion during surgery." "An indwelling urinary catheter will be inserted after surgery." "My husband can wait in the nursery to see the baby after it is born." "My husband can be present during the birth."
The patient at 38 weeks os gestation, 3 cm dilated, 50% effaced, -5 station, with ruptured membranes The patient with the greatest risk for a prolapsed cord is the patient who is at 38 weeks of gestation, 3 cm dilated, 50% effaced, -5 station, with ruptured membranes. The fetal head is not engaged in the pelvis to prevent the cord from prolapsing if the amniotic membranes rupture. When the presenting part of the fetus is engaged, the risk of cord prolapse diminishes.
The nurse is reviewing the histories of laboring patients on the unit. Which patient should the nurse identify as having the highest risk for a prolapsed cord? The patient at 38 weeks os gestation, 3 cm dilated, 50% effaced, -5 station, with ruptured membranes The patient at 40 weeks of gestation, 8 cm dilated, 75% effaced, 0 station, with intact membranes The patient at 39 weeks of gestation, 9 cm dilated, 100% effaced, +1 station, with ruptured membranes The patient at 38 weeks of gestation, 3 cm dilated, 80% effaced, 0 station, with intact membranes
The patient is dilated 9 cm and is 100% effaced. The transition phase is the shortest phase of the first stage of labor and is defined by a cervical dilation of 8-10 cm and effacement of 100%. A patient who is dilated 6-8 cm is in the active phase of labor. The patient who is dilated 3 cm or less is in the latent phase of labor.
The nurse is reviewing the report on a patient who is in the transition phase of labor. Which assessment finding does the oncoming nurse anticipate based on the patient's phase of labor? The patient is dilated 7 cm and is 50% effaced. The patient is dilated less than 3 cm and is 20% effaced. The patient is dilated 5 cm and is 30% effaced. The patient is dilated 9 cm and is 100% effaced.
Second The baby's head will crown during the second stage of labor. The second stage of labor begins with complete cervical effacement and dilation and ends with the birth of the baby. The first stage of labor starts with the onset of labor and ends with complete cervical dilation. The third stage of labor starts with the delivery of the fetus and ends with the delivery of the placenta. The fourth stage of labor begins with the delivery of the placenta and ends 1-4 hr after delivery.
The nurse is reviewing the stages of labor with a patient. The patient asks, "In which stage of labor will my baby's head start crowning?" Which response by the nurse is correct? Second First Fourth Third
Bloody show Bloody show is considered a sign that labor will begin within 48 hours. Women may experience a sudden burst of energy a week or so before the onset of labor, not necessarily fatigue. An increase in vaginal discharge occurs prior to the onset of labor. Breathing becomes easier when the fetus descends and the fundus no longer presses on the diaphragm.
The nurse is teaching a patient about the signs of impending labor. Which information should the nurse include as a premonitory sign of labor? Increased difficulty breathing Decreased vaginal discharge Bloody show Fatigue
The patient begins with a cleansing breath and then inhales and exhales through the mouth with punctuated breathing every few breaths by a forceful exhalation through pursed lips. Effective use of pant-blow breathing is demonstrated by the patient beginning with a cleansing breath, then inhaling and exhaling through the mouth with punctuated breathing every few breaths by a forceful exhalation through pursed lips. Abdominal breathing is described as the patient moving the abdominal wall outward as they inhale and inward as they exhale. Modified-paced breathing is initiated after a cleansing breath, The patient pushes out a short breath and then inhales and exhales through the mouth at a rate of about four breaths every 5 seconds. A cleansing breath can be described as the patient inhaling slowly through the nose, moving the chest up and out during the inhalation, and exhaling through pursed lips.
The nurse is teaching about pant-blow breathing for the patient breathing too rapidly. Which describes this breathing pattern? After a cleansing breath, the patient pushes out a short breath and then inhales and exhales through the mouth at a rate of about four breaths every 5 seconds. The patient moves the abdominal wall outward as they inhale and inward as they exhale. The patient begins with a cleansing breath and then inhales and exhales through the mouth with punctuated breathing every few breaths by a forceful exhalation through pursed lips. The patient inhales slowly through the nose, moves the chest up and out during the inhalation, and exhales through pursed lips.
