LABOR, DELIVERY & POSTPARTUM

The nurse is assessing a patients blood pressure during labor. The patient asks why her blood pressure is measured so frequently. The nurse explains that:

"Blood pressure changes may affect the fetus." Frequent BP monitoring is needed because changes in BP can affect fetal blood supply. " Following the blood pressure changes allows us to track your contractions." Monitoring of contraction intensity and duration is aided by monitoring of BP to recognize when a patient is having a contraction, even when she may not feel it (f she has an epidural). "Blood pressure changes can be a side effect of the medications you have been given." Many medications given in labor affect BP and this should be explained to the patient.

A patient has been prescribed to oral contraceptives. Which statement by the patient indicates the need for further education?

"Once I start this medication, I dont need to use condoms." -The patient should be instructed to use a back up method of birth control for the first 7 days of taking oral contraceptives.

A postpartum patient is experiencing urinary retention. The nurse would expect the physician to order which drug, in order to stimulate bladder contractions?

-Bethanechol (Urecholine) is a cholinergic agent that stimulates muscarinic receptiors. -Atropine, Benztropine (Cogentin), and Scopolamine (Hycosine) are all anticholinergic drugs and would worsen urinary retention.

The nurse is assisting a patient who just delivered a healthy baby boy weighing 3,500 grams. Upon cord traction of placenta, there is a sudden gush of a large amount of blood. The fundus is no longer palpable in the abdomen. Which of the following nursing interventions are most appropriate?

-Check established IV patency, do not attempt to remove the placenta, assess vital signs, notify the health care provider. -Uterine inversion is a medical emergency in which the inner uterine lining collapses into the vagina. -Heavy vaginal bleeding will be seen, and the fundus is unable to be palpated in the abdomen. -If not corrected immediately cervical entrapment of the uterus may occur. -Risk factors include straining after the delivery, too vigorous kneading of the fundus, or pulling on the cord before the placenta has separated. -The health care provider and RN should be notified immediately and IV fluid replacement is expected for blood loss. -The nurse anticipates this and prepares equipment. -Administering oxytocic drugs only compound the inversion; uterotonic drugs should be discontinued to allow uterine relaxation for replacement.

A woman is completely dilated and at +2 station. Her contractions are strong and last 50 to 70 seconds. Based on this information, the nurse should know that the patient is in which stage of labor?

-Considering that the woman has already reached full cervical dilation and already lies at +2 station, the nurse should anticipate caring for the mother at the second stage of labor. -The presenting part is not below the ischial spines. As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense. -The circle enlarges until the fetus is pushed out of the birth canal. -First stage of labor starts from onset of regularly perceived uterine contractions and ends with full cervical dilation. -Third stage of labor (placental stage) follows after the expulsion of the infant and ends with the delivery of the placenta. -The fourth stage of labor follows placental expulsion to 1-4 postpartum.

The nurse is caring for a woman in labor. What signs would indicate that the patient is in the transition phase of labor?

-During the transition phase of the first phase of labor, the maximum cervical dilation of 8 to 10 cm occurs, contractions reach their peak of intensity and occurring every 2 to 3 minutes and a duration of 60 to 90 seconds. -During transition phase, the woman may experience intense discomfort so strong it is accompanied by nausea and vomiting. -Because of the intensity and duration of the contractions, she may experience a feeling of loss of control, anxiety, panic and irritability. Since dilation continues at a rapid rate, the membranes rupture and heavy show is present.

A woman who has been in labor for 6 hours is now 9 cm dilated and has intense contractions every 1 to 2 minutes. She is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take?

-Encourage panting through contractions to prevent pushing. -Since the woman has not reached full cervical dilation, which is 10 cms, it is best for the nurse to encourage the woman to breath, using repeated short puffs to prevent pushing. -Allowing the woman to push without a fully dilated cervix will predispose her to bleeding and cervical laceration. -During this time, the woman has already reached the transition phase of the first stage of labor. -The contractions have reached its peak of intensity, occurring 1 to 2 minutes. -A woman in this phase may experience intense discomfort, so strong that she may also experience a feeling of loss of control, anxiety, panic, and irritability. -During first stage of labor, it is best to position the woman in the left side lying position. -This position causes the heavy uterus to tip forward, away from the vena cava, allowing blood return from the lower extremities and adequate placental filling and circulation. -During Transition phase, the woman often becomes irritable and restless. The patient may resist being touched and push away.

Which of the following signs in a postpartum patient would make the nurse concerned for endometritis?

-Endometritis is an infection/inflammation of the endometrium (lining of the uterus). -It can occur during pregnancy or after childbirth. -Endometritis may be caused by organisms that are normal inhabitants of the vagina and cervix; however, organisms such as gonorrhea and chlamydia may be frequently encountered during pregnancy. -If left untreated, these infections may lead to postpartum endometritis and a potential for maternal and/or neonatal morbidity. -Major signs and symptoms of endometritis are fever, chills, malaise, lethargy, anorexia, abdominal pain, and cramping, uterine tenderness and purulent, foul smelling lochia.

A 30 year old primipara is administered an epidural anesthesia. During the first hour of post epidural anesthesia administration, which of the following signs and symptoms should be referred immediately to the anesthesiologist?

-Epidural anesthesia can cause serious potentially life threatening complications, safe and effective management requires a coordinated multidisciplinary approach it can cause respiratory depression if opioids are used. -Side effects of Epidural opioids may include nausea and vomiting, pruritus and delayed maternal depression. -The possibility of late respiratory depression exists for up to 24 hours after the administration of an epidural opioid, depending on the duration of action of the drug used.

In planning nursing care for a patient with cardiac disease, the nurse would question which of the following physician orders:

-High fluid intake. -An excessive fluid intake in a patient with cardiac disease is already at risk for fluid overload due to the extra accumulation of fluid from pregnancy. -Monitoring input and output of the patient is the top priority of the nurse to prevent risk of fluid overload. -Vital signs should be monitored every 2-4 hrs to monitor the cardiac condition of the patient. -High fiber diet is recommended to prevent constipation and straining.

The nurse is assessing a patient after delivery and finds the uterine fundus boggy and one centimeter above the umbilicus. Which of the following is the priority nursing intervention?

-If there is uterine atony, the first priority intervention of the nurse is to control hemorrhage by attempting uterine massage to encourage contraction. -Contraction will compress the vessels and reduce blood flow. -When the uterus is firm, observe the perineum for passage of clots and blood. -Assess vital signs after ensuring that the uterus is well contracted.

A 24 year old primipara is now on her active phase of first stage of labor. She tells the nurse that she wants a general anesthesia to relieve intense pain. The nurse advises the patient that general anesthesia is never preferred for childhood because:

-It carries the dangers of hypoxia and possible inhalation of vomitus during administration. -General anesthesia administration is never preferred for childbirth, because it carries the dangers of hypoxia and possible inhalation of vomitus during administration. -Pregnant women are particularly prone to gastric reflux because of increased stomach pressure from the weight of the full uterus beneath it. -All women who receive general anesthesia must be observed closely in the postpartum period because of the possibility of uterine atony and hemorrhage.

A patient has requested an oral contraceptive to reduce the risk of pregnancy. The physician prescribes ethinyl estradiol 30-drospirenone 3 to be cycled for 21 days and followed by a 7 day break. Which classification of contraceptive is ethinyl estradiol 30-drospirenone 3?

-Monophasic. Ethinyl estradiol 30-drospirenone 3, trade name Yasmin, is a monophasic oral contraceptive. -Monophasic contraceptives contain the same dose of estrogen and progesterone for the entire dosing schedule. -The patient receives 21 days of the active drug, which if then followed by a 7 day period of a placebo to allow withdrawal bleeding. -Mutiphasic contraceptives contain both estrogen and progesterone at different dosages throughout the cycle.

A patient is admitted at 22 weeks gestation for preterm labor. The nurse administers nifedipine (Procardia) as ordered. The patient is most likely to complain of which side effects?

-Nifedipine (Procardia) is a calcium channel blocker that is commonly used to delay premature labor. -Common side effects include headache, dizziness, edema, flushing, nausea, and gingival hyperplasia.

A patient is admitted to the hospital to deliver through labor induction. The nurse administers oxytocin (Pitocin) as ordered by the physician. Knowing the potential complications of oxytocin (Pitocin), the nurse should closely monitor:

-Oxytocin (Pitocin) stimulates uterine contractions, which can cause decreased fetal heart rate and hypoxia. -The nurse should closely monitor the fetal heart rate for any changes.

The nurse is caring for a primagravida 1 para 0 client without complications who is near the end of the first stage of labor. Which nursing diagnosis is most appropriate at this time?

-Potential fluid volume deficit related to decreased intake of fluids. -Adequate intake of fluids and nourishment is needed to maintain hydration and energy during the early stage of labor. -Traditionally fluids were restricted during labor to only ice chips due to risk for aspiration should a maternal client require anesthesia; however, that practice has been challenged due to the predominance of regional anesthesia for c-section. -The nurse should recognize that clients have inadequate intake of fluids during the first stage of labor due to delayed gastric emptying and decrease PO intake. -The nurse should allow the intake of clear fluids as tolerated. For an uncomplicated labor, placental perfusion would not be hindered by the client who may reposition ad lib. Primagravida indicates this is the clients first pregnancy.

A nurse teaches parents who moved into a home with lead pipes. What does the nurse most correctly teach the parents about formula preparation for a six month old infant?

-Run cold tap water for two minutes and store for use in mixing formula. Most bottled water does not contain fluoride, a fluoride supplement may be necessary. -Also, some bottled waters have not been tested and may not be appropriate for consumption. This is also a costly option. -The EPA and CDC recommend running cold tap water, not hot, for 30 seconds to 2 minutes, filling jugs for later, and using this water for drinking use. -Boiling water does not reduce lead in the water. However, boiling water for exactly one minute reduces other contaminants and could be done after running cold water for storage. -Liquid formulations of infant formula are considered sterile, powder is not, and its use is sometimes warranted, especially for infants under three months of age and premature infants. -For the older infant, liquid formula is quite expensive, the infant is drinking more, and is less susceptible to infection from powdered formula.

The nurse should perform which of the following nursing actions when a patient with preeclampsia has a seizure during the postpartum period?

-Stay with the patient, administer O2, position to prevent aspiration, and maintain a safe environment. -The best choice is to stay with the patient, raise the handrails, and ensure safety of the patient from fall and injury. -Administration of O2 by face mask will help maintain adequate oxygenation and prevent bradycardia. -To prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth.

A new mother with pregnancy induced hypertension calls the hospital complaining of severe headache and blurred vision. How should the nurse respond?

-Tell the patient to hang up and call 911 immediately. -The patient is having symptoms of severe hypertension, which puts her at risk for seizures. -The patient needs to be treated ASAP in order to reduce her BP and prevent complications. -Pregnancy induced hypertension can last several weeks after delivery.

Which of the following of Leopolds maneuvers should the nurse use to determine if the presenting part of the fetus is engaged?

-The 3rd maneuver determines the part of the fetus at the inlet and its mobility. If the presenting part moves upward so an examiners hands can be pressed together, the presenting part is not engaged. -The 1st maneuver determines fetal part lying in the fundus and the fetal presentation. -The 2nd maneuver determines which direction the fetus's back is facing. -The 4th maneuver determines the fetal attitude and degree of flexion of the fetal head.

A nurse is caring for a patient in need of birth control. The patient questions the nurse about the proper method of using a diaphragm.

-The diaphragm should be left in place for 6 hours after intercourse. -Acting as a reservoir for spermicide, the diaphragm must be left in place for 6 hours after intercourse to be effective. -Having a diaphragm in place at all times is not recommended. -Not using spermicide or removing the diaphragm immediately after intercourse will decrease the effectiveness.

A woman receives a rubella vaccination while in the hospital. The nurse would give her which of the following instructions?

-The rubella vaccine should not be administered to women who are pregnant or plan on becoming pregnant within 28 days. -There is a theoretical possibility that the infant will contract congenital rubella syndrome. -The patient should be instructed to use effective birth control for at least 28 days.

Claire delivered a 3,400 gram baby boy and was transferred to the postpartum unit. On the second postpartum day the patient experiences tenderness and breast engorgement from breast feeding. To relieve her discomfort the nurse should encourage the patient to:

-Warm compresses should be applied between feedings to reduce discomfort. -Cold compresses can be applied if the patient is not breast feeding. -Breast milk forms in response to the fall of estrogen and progesterone levels that follows delivery of the placenta. When the production of milk begins, the milk ducts become distended. -The breasts become fuller, larger and firmer. The distention is not limited to the milk ducts, it also occurs in the surrounding tissue. -The feeling of tension in the breast on the third or fourth day is termed primary engorgement. -Do not discontinue breastfeeding. Primary engorgement fades as the infant begins effective sucking and empties the breasts of milk. -Do not remove the bra because a supportive bra provides pain relied and comfort to engorged breasts.

A patient is having trouble adjusting to breastfeeding, and is disagreeing with her husband on the importance of breastfeeding compared to formula. Which member of the health care team should the nurse consult?

A lactation consultant is trained to answer questions about breastfeeding and can best discuss these issues with the patient and her husband.

A nurse is providing care to a woman 38 weeks pregnant. During the most recent vaginal examination, the nurse notes that the cervix is 6 cm dilated, 100% effaced, with the vertex at -1 station. What is the best interpretation?

Active labor with the head as presenting part, not yet engaged. The best interpretation is that the woman is in active labor with the head as presenting part. This is because cervical dilation is 6 cm and not yet engaged (the vertex lies at -1 station). -Transition phase and Latent phase are incorrect because the cervical dilation, which is 6 cm, is in the active phase of the first stage of labor. -Transition phase starts to peak in contractions and dilation of 8 to 10 cms. Furthermore, Latent phase is the onset of the first stage of labor and is when cervical dilation begins.

The nurse is caring for a woman in the first stage of labor. The fetal position if left occiputoanterior. When her membranes rupture, the nurses first action should be to:

Assess the fetal heart rate. The first stage of labor is the longest and involves 3 phases: Latent phase: onset to 4 cm dilation/contractions 15-30 min apart, 15-30 secs long. Active Phase: 4 to 7 cm dilation/contractions 3-5 min apart, 30-60 seconds long. Transition: 8 cm to fully dilated/ 10 cm/contractions 2-3 min apart/ 45-90 seconds long. -Counting the fetal heart rate before, during, and after contractions is important to ensure the well being of the fetus. -FHR should be 110-160 BPM. -Labor may begin with rupture of the membranes. -If membranes rupture, first assess the FHR due to the risk of a collapsed umbilical cord, and then assess the color and clarity of the amniotic fluid to look for meconium staining, which would indicate fetal distress. Report any unusual findings ASAP! -Early rupture of the membranes can be advantageous if it causes the fetal head to settle snugly into the pelvis. -However, intrauterine infection or prolapse of the umbilical cord are two risk factors associated with prolonged membranes during a long first stage of labor. -Measuring the amount of fluid should only be done if the patient is experiencing oligohydramnios or hydramnios.

The nurse assesses a postpartum patient as having moderate lochia rubra with clots on her second postpartum day. Which of the following interventions would be appropriate?

Assess the fundus and bladder status. To assess involution process, the nurse should palpate the fundus to see if it is firm and well contracted. During birth, the fetal head exerts pressure on the bladder and urethra as it passes on the bladders underside. -This pressure may leave the bladder with a transient loss of tone. -To prevent permanent damage to the bladder from over distention, assess the woman's abdomen frequently. -Lochia rubra is a postpartum vaginal discharge consisting almost entirely of blood. -There are often small particles of deciduas and mucus during the first 3 postpartum days.

Which of the following clinical manifestations is a priority for the nurse to report on a woman in the second stage of labor?

Indentation across the abdomen and persistent vaginal bleeding. -An indentation across the abdomen, abdominal pain, or vaginal bleeding during the second stage of labor should be reported to the physician. -These symptoms are signs of impending rupture of the uterus and is a medical emergency! -During this time the woman will experience uncontrollable urges to push or bear down with contractions. -As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense.

A patient was transported to the post anesthesia care unit (PACU) after a c-section. The PACU nurse was informed that the patient received epidural anesthesia for the procedure. What is the safest position for this patient?

Post operative patients who have received epidural anesthesia must be positioned in semi-Fowlers position to prevent upward migration of the opioid in the spinal cord, thus decreasing the risk for respiratory depression.

A patient has meconium stained amniotic fluid. Fetal scalp sampling indicates a blood ph of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action?

Prepare for c-section. -Based on the assessment, fetal acidosis is present. Infants with meconium stained amniotic fluid may have respiratory difficulties and bradycardia at birth. -These findings pose a great threat to the newborns well being. Therefore, a c-section is required. -Amnioinfusion is an infusion of sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression. This is also done to dilute meconium in amniotic fluid, reducing the risk that the infant will aspirate thick meconium at birth. This procedure is done only if the patient does not experience fetal hypoxia.

A patient in labor is being monitored for contractions. Which of the following should the nurse document related to contractions?

The nurse needs to document uterine contractions. This includes frequency, intensity, and duration of contractions. Dilation of the cervix should be documented separately from uterine contractions. Patient position can affect the length of labor and this should be documented in the patients chart.

A nurse is caring for a patient that is 6 cm dilated. The nurse should follow the protocol for care of the patient in:

The patient is in the active phase of the first stage of labor when the cervix is dilated from 5 to 8 cm. -First stage of labor is the period from onset of true labor to full cervical dilation. This stage has 3 phases latent, active, and transition. -The latent phase begins at the onset of regular uterine contractions and ends with rapid cervical dilation of 1 to 5 cm. Contractions occur every 15 to 30 minutes and are 15 to 30 seconds in duration with mild intensity. -The transition phase is the last and final phase of the first stage of labor. During this phase, contractions reach their peak and intensity, occurring every 2 to 3 minutes. Cervical dilation increases from 8 to 10 cm.

After performing Leopolds maneuvers on a patient in labor, the nurse should prepare the patient for a vaginal delivery after determining if the fetus is in which of the following positions?

The vertex presentation is the most favorable presentations for normal vaginal birth. The fetus's head is the first part to contact the cervix and the fetus long axis is parallel with the long axis of the mother. -Transverse lie poses a difficult presentation for vaginal birth. This would put both the mother and child in jeopardy. If is advisable to have a cesarean section since the fetus is lying horizontally in the pelvis. -Oblique lie is a situation in which the long axis of the fetal body crosses that of the maternal body. If the fetal lie is not in line with the mothers spine, a c-section may be required.