Intrapartum Period NU201 EXAM 3
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation? occiput posterior position transverse lie compound presentation breech position
Correct response: breech position Explanation: Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? fetal prematurity rapid, progressive labor insufficient perineal stretching umbilical cord prolapse
Correct response: umbilical cord prolapse Explanation: Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? Change the client's position. Administer oxygen. Prepare for emergency cesarean birth. Check for placenta previa.
Correct response: Change the client's position. Explanation: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? dilation, duration, and frequency duration, frequency, and intensity dilation, effacement, position frequency, duration, maternal position
Correct response: duration, frequency, and intensity Explanation: The nurse should document the duration, frequency, and intensity of uterine contractions. Dilation refers to the number of centimeters the cervix is dilated; it doesn't describe uterine contractions. Maternal position doesn't help describe uterine contractions. Dilation and effacement both refer to the condition of the cervix, not uterine contractions.
A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? Perform a straight catheterization for protein analysis. Complete an initial assessment on a client. Assess a laboring client for a change in labor pattern. Increase the oxytocin rate on a laboring client.
Correct response: Perform a straight catheterization for protein analysis. Explanation: The straight catheterization is within the scope of practice of a licensed practical nurse. An initial or continuing assessment is the responsibility of the registered nurse. Assessment must be complete before increasing the IV rate of oxytocin. The assessment and the increase in oxytocin rate are responsibilities for the nurse.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse should contact the health care provider (HCP) for clarification in what circumstance? The client's membranes have ruptured. The client is exhibiting hypotonic labor patterns. The client has been diagnosed with type 2 diabetes. The client's pregnancy is multifetal.
Correct response: The client's membranes have ruptured. Explanation: Some HCPs do not allow clients with ruptured membranes to use a hot tub or jet hydrotherapy tub during labor for fear of infections. The nurse should check with the HCP before continuing. Jet hydrotherapy is not contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns.
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client? prone supine right lateral left lateral
Correct response: left lateral Explanation: The fetal heart rate monitoring strip shows late decelerations, which indicate uteroplacental circulatory insufficiency and can lead to fetal hypoxia and acidosis if the underlying cause is not corrected. The client would be turned onto her left side to increase placental perfusion and decrease contraction frequency. In addition, the intravenous fluid rate may be increased and oxygen administered. The right lateral, supine, and prone positions do not increase placental perfusion.
A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse? Perform sterile vaginal examination, increase IV fluids, and apply oxygen. Prepare for birth, reposition the patient, and begin pushing. Notify the provider, explain findings to the client, and begin pushing. Reposition the client, apply oxygen, and increase IV fluids.
Correct response: Reposition the client, apply oxygen, and increase IV fluids. Explanation: Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.
The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? chest head umbilical cord placenta
Correct response: umbilical cord Explanation: Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.
The nurse is caring for a client during the fourth stage of labor. Which complications is the nurse most alert for at this time. Select all that apply. Urinary retention. Arrhythmias. Dizziness. Hemorrhage. Mastitis.
Correct response: Hemorrhage. Dizziness. Urinary retention. Explanation: The fourth stage of labor involves the first 1 to 4 hours after birth. During this stage, the mother and neonate adjust physiologically to the birth, and the mother is at risk for hemorrhage. Urinary retention may happen because of swelling. Exhaustion, fluid loss can cause dizziness. Arrhythmias are not typical, but heart rate decreases to 50 to 70 beats/minute. Infection and mastitis are complications that may occur later in the postpartum period.
The nurse has just received report on a labor client: a G3, T1, P0, Ab1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will include address what factors? Select all that apply. Transition will be shorter for this multiparous client. This client will withdraw into herself during transition. Contractions will remain irregular until transition. Stage 2 should take 30 minutes or less. Birth should occur before the change of shift in 12 hours.
Correct response: Birth should occur before the change of shift in 12 hours. Stage 2 should take 30 minutes or less. Transition will be shorter for this multiparous client. This client will withdraw into herself during transition. Explanation: A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition, and this is a common characteristic for those in the transition phase.
The nurse is teaching a prenatal class and is discussing different stages of labor. Which of the following statements made by a class member demonstrates that the instruction was effective? Select all that apply. "When I am dilated 8 cm, I will start pushing." "A shower may provide comfort during the active phase of labor." "Contractions will be every 10-20 minutes in the latent phase." "I'll need to have more support during the transition." "I can receive an epidural during the active phase of labor."
Correct response: "Contractions will be every 10-20 minutes in the latent phase." "I'll need to have more support during the transition." "A shower may provide comfort during the active phase of labor." "I can receive an epidural during the active phase of labor." Explanation: Pushing occurs after the client is dilated 10 cm. Depending on the facility or healthcare provider, the healthy client generally needs to be in active labor and a certain dilation before an epidural can be administered. If the client has a medical need, such as a cardiac condition, the epidural may be given early. A shower may provide comfort during the active phase of labor. The latent phase of labor is the first phase of stage one of labor and uterine contractions can vary from 10 to 20 minutes apart. Transition is dilation of the cervix from 8 cm to 10 cm. During this time, the client's contractions increase in frequency and intensity. The client will need more support during this time.
External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first? Prepare the client for a cesarean birth. Change the client's position. Notify the anesthesiologist. Administer oxygen at 2 L by mask.
Correct response: Change the client's position. Explanation: Variable decelerations, common after membranes rupture, usually indicate cord compression. Repositioning the client often helps to correct this fetal heart rate pattern. If repositioning is not successful, the clinician may choose to perform amnioinfusion of sterile saline solution into the uterus through a sterile catheter to help take the pressure off the cord.The nurse may wish to alert the obstetrician or nurse midwife, but the anesthesiologist is responsible for anesthesia, not for the fetus.Administering oxygen at 2 L is not helpful because pressure on the cord must be relieved first.Changing the client's position and administering oxygen often resolve the cord compression. There is no need to prepare the client for a cesarean birth at this time. A cesarean birth would be indicated for prolonged fetal distress.
A client with gestational diabetes has delivered a large-for-gestational-age (LGA) neonate with mild grunting and irritability. The nurse performs the actions in what order? Place the options in order from first action to last. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Start an intravenous line. 2Check vital signs, including SaO2. 3Administer prescribed medications. 4Obtain a chest X-ray. 5Give 40% FiO2 at 1-2 liters per minute. 6Obtain a blood sample.
Correct response: Check vital signs, including SaO2. Give 40% FiO2 at 1-2 liters per minute. Obtain a blood sample. Start an intravenous line. Administer prescribed medications. Obtain a chest X-ray. Explanation: First, the nurse must assess to determine priorities. The LGA neonate is at increased risk for respiratory complications including respiratory distress syndrome. Grunting indicates increased work of breathing, so airway is the next priority, including application of oxygen. The LGA is also at risk for hypoglycemia and polycythemia, so labs need to be drawn to direct the need for pharmacological treatments. Because lab results take time, a blood sample must be collected and sent as soon as possible. Though the nurse can assess glucose level more quickly using a glucometer, other tests are needed, including CBC with differential, electrolytes, and bilirubin. After collecting the sample, intravenous access is established to facilitate medication administration. Based on the lab results, some immediate medications may be required, such as glucose, calcium, and magnesium to correct hypoglycemia and electrolyte imbalances that are more common in LGA neonates. Finally, once the infant is stable, X-rays may be done.
A woman who gave birth to her last infant by caesarean birth is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo "a trial labor." What does the nurse explain to the client that trial of labor means? The HCP needs more information to determine the presence of true labor. Labor will be arrested with tocolytic agents after a 2-hr period even if no fetal distress is noted. Labor will be stimulated with exogenous oxytocin until delivery. Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery.
Correct response: Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: A trial labor in this context means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to delivery. If there are indications that labor is not progressing, other means of delivery are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicates true labor. If fetal distress is noted and an emergency cesarean birth cannot be done immediately, tocolytic agents may be considered to stop contractions.
The nurse receives the following report on a client: "This is a 25-year-old G2P1 with contractions every 3 to 4 minutes lasting 60 seconds. The fetal heart tracing shows the baseline to be 125 with moderate variability. Membranes ruptured 2 hours ago and the cervix is 5 cm, 90% effaced, with a station of -2. The presenting part is engaged." What interventions would the nurse include in the client's plan of care? Select all that apply. Place the client on bed rest. Place a cool cloth on the client's forehead. Offer a back rub or effleurage. Assess temperature every 4 hours. Assist the client in pushing techniques.
Correct response: Offer a back rub or effleurage. Place a cool cloth on the client's forehead. Explanation: The client is in the active phase of labor with her membranes ruptured. Offering a backrub, or effleurage, and placing a cool washcloth to the client's forehead are appropriate interventions. Placing the client on bed rest is not necessary. Assessment of the temperature should be every 2 hours. Pushing does not occur until the client is fully dilated.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. It doesn't matter which client receives priority; they're at the same stage of labor. Triage observation is appropriate for both clients at this time. The nurse should assign priority to the first client. Her leaking amniotic fluid indicates that she'll soon go into labor.
Correct response: The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. Explanation: Regular contractions 3 minutes apart and 1 minute in duration along with an urge to push, as exhibited in the second client, indicate a pending delivery. Priority should be assigned to this client. Leaking amniotic fluid that appears to be clear, as exhibited in the first client, doesn't indicate that contractions are about to begin. This client is less of a priority.
The nurse has obtained a urine specimen from a multiparous client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply. allowing her support person to take her to the bathroom to maintain privacy applying an external fetal monitor to obtain fetal heart rate assisting her to the bathroom assessing her stage of labor checking the degree of fetal descent asking if she had back labor pains like this with any of her other births
Correct response: assessing her stage of labor checking the degree of fetal descent Explanation: The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near birth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a birth in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however, it does not help to determine if the fetus is ready to be born, which is the higher priority in this situation. Regardless of the client's prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a bowel movement.
While a client is being admitted to the birthing unit she states, "My water broke last night, but my labor started two hours ago." Which findings are a concern? Select all that apply. maternal vital signs: T 99.5° F (37.5° C), HR 80, R 24, BP 130/80 mm Hg client stating, "This baby wants out—he keeps kicking me." baseline fetal heart rate of 140 with a range between 110 and 160 with contractions blood and mucus on perineal pad peripad stained with green fluid
Correct response: baseline fetal heart rate of 140 with a range between 110 and 160 with contractions peripad stained with green fluid client stating, "This baby wants out—he keeps kicking me." Explanation: The range of fetal heart rate fluctuating too high and low could indicate fetal distress. The green peripad fluid indicates meconium, which could be associated with fetal distress. Increased fetal activity during labor may also indicate distress. The maternal vital signs noted and a perineal pad with blood and mucus are normal findings.
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? chaplain, because his educational background includes strategies for handling grief social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff human resource director, so she can arrange vacation time for the staff physician, so he can provide education about HELLP syndrome
Correct response: chaplain, because his educational background includes strategies for handling grief Explanation: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.
The nurse assesses the client for active phase of labor who has just received continuous epidural anesthesia. What common side effects would the nurse teach the client about with this type of anesthesia? Select all that apply. loss of bowel control hypotension rales loss of bladder control pruritis
Correct response: loss of bladder control pruritis hypotension Explanation: Common side effects with continuous epidural anesthesia includes hypotension, loss of bladder control, and pruritis. This does not include loss of bowel control and rales. Typically, the effects of the epidural anesthesia are noted below a specific level on the body. This level may be determined by the anesthetist. A high insertion level may result in sparing of nerve function in the lower spinal nerves. For example, a thoracic epidural may be performed for upper abdominal surgery, but may not have any effect on the perineum (area around the genitals) or pelvic organs. Nonetheless, giving very large volumes of fluid into the epidural space may spread the block both higher and lower.
A primigravid client is admitted as an outpatient for an external cephalic version. Which factor would be a contraindication for the procedure? maternal Rh-negative blood type multiple gestation breech presentation history of gestational diabetes
Correct response: multiple gestation Explanation: External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent the need for a cesarean birth. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie. Contraindications to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, severe oligohydramnios (decreased amniotic fluid), contraindications to a vaginal birth (e.g., cephalopelvic disproportion), and unexplained third trimester bleeding. If the mother has Rh-negative blood type, the procedure can be performed and Rh immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational diabetes is not a contraindication unless the fetus is large for gestational age and the client has cephalopelvic disproportion.
The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time? methergine magnesium sulfate terbutaline oxytocin
Correct response: oxytocin Explanation: An epidural can slow contractions, so many clients will need to have oxytocin to maintain contraction strength. Magnesium sulfate and terbutaline are tocolytic medications to decrease contractions, and methergine is used for postpartum hemorrhage.
A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? dinoprostone 10 mg oxytocin 30 units in 500 ml D5W prostaglandin gel 0.5 mg misoprostol 50 mcg
Correct response: oxytocin 30 units in 500 ml D5W Explanation: A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place.
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus maternal sexually transmitted disease Rh incompatibility between mother and fetus maternal intrauterine infection
Correct response: passage of meconium by the fetus Explanation: Greenish-colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal system of the neonate, especially those neonates who are full term or of postdate gestational age. Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.
The nurse is admitting a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What actions will the nurse perform with planning and providing the client's care? Select all that apply. Keep dedicated equipment in the client's room. Double-bag any laboratory specimens that are taken from the client. Assign the client to a private room. Wear a gown, gloves, and mask when providing direct care. Place the client on droplet precautions, and document this action clearly
Correct response: Assign the client to a private room. Keep dedicated equipment in the client's room. Explanation: Clients who are colonized with MRSA should be housed in a single-client room whenever possible, and dedicated equipment should be kept in the room. A gown and gloves are necessary when providing care, but a mask is unnecessary unless there is a realistic possibility of airborne or droplet contamination. Nothing in this client's history suggests that droplet precautions should replace contact precautions.
