Maternal-Newborn chapter 16- Labor & Delivery

Administration of 500 mL of IV Ringer's lactate

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? Administration of 500 mL of IV Ringer's lactate Administration of 1000 mL of IV glucose solution Move the woman into a supine position Administration of aspirin

maternal hypotension and fetal bradycardia

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia maternal hypertension and fetal tachycardia

implementing measures for a vaginal birth

A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? implementing measures for a vaginal birth preparing the client for a cesarean birth assisting with artificial rupture of the membranes instituting continuous internal fetal monitoring

cervical dilation of 6 cm contractions lasting up to 60 seconds

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply. cervical dilation of 6 cm contractions every 1 to 2 minutes cervical effacement of 90% contractions lasting up to 60 seconds strong desire to push

fetal hypoxia effect of maternal analgesia prolonged umbilical cord compression

A nurse is reviewing the FHR and notes it to be in the range of 100 to 106 bpm over the past 10 minutes. Which conditions might the nurse suspect as the cause? Select all that apply. fetal hypoxia effect of maternal analgesia prolonged umbilical cord compression maternal fever prematurity

cervical dilation of 2 cm or more

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? intact membranes cervical dilation of 2 cm or more floating presenting fetal part a neonatologist to insert the electrode

Assess fetal heart rate for fetal safety.

During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs? Turn the patient onto the left side. Assess fetal heart rate for fetal safety. Test a sample of amniotic fluid for protein. Instruct to bear down with the next contraction.

ischial spine

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks? ischial spine ischial tuberosity pubic symphysis cervical os

Identify how the client expresses labor pain.

In providing culturally competent care to a laboring woman, which is a priority? Identify the decision maker within the family. Identify any cultural foods used prior to labor. Identify who is the support person during the labor. Identify how the client expresses labor pain.

administration of oxygen by mask

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? application of vibroacoustic stimulation tactile stimulation administration of oxygen by mask fetal scalp stimulation

fetal status

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? Risk factors Maternal status Fetal status Maternal obstetrical history

The mother may have difficulty working effectively with contractions.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? The father's coaching role may be disrupted at times. The infant may show increased drowsiness. The mother may have continued memory loss postpartum. The mother may have difficulty working effectively with contractions.

FHR

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? FHR signs of infection fetal position maternal comfort level

Assess fetal heart rate for fetal safety.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Test a sample of amniotic fluid for protein. Ask her to bear down with the next contraction. Elevate her hips to prevent cord prolapse. Assess fetal heart rate for fetal safety.

The client's cervix is fully dilated.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client's cervix is fully dilated. The infant is born. The client has contractions once every two minutes. The client experiences her first full contraction.

Clear to straw-colored fluid

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? Bloody fluid Clear to straw-colored fluid Greenish fluid Cloudy white fluid

"The injection is given in the space outside the spinal cord."

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? "An injury is unlikely because of expert professional care given." "I have never read or heard of this happening." "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem." "The injection is given in the space outside the spinal cord."

Significant head molding

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? Thick vernix Single palmar crease Significant head molding Absence of testicular rugae

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. Turn the client on her left side. Reduce intravenous (IV) fluid rate. Administer oxygen by mask. Assess client for underlying causes. Ignore questions from the client.

Long axis of fetus is perpendicular to that of client.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? Long axis of fetus is at 60° to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is at 45° to that of client.

Ask the woman to describe why she believes that she is in labor.

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? A) Tell the woman to stay home until her membranes rupture. B) Emphasize that food and fluid should stop or be light. C) Ask the woman to describe why she believes that she is in labor. D) Arrange for the woman to come to the hospital for labor evaluation.

Ensure cervix fully dilated

A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritize at this time? Evaluate maternal vital signs Ensure cervix fully dilated Evaluate fetal heart monitor Ensure empty urinary bladder

EFFLEURAGE

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: effleurage. acupressure. patterned breathing. therapeutic touch.

"She is in active labor; she is progressing at this point and we will keep you posted."

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? "She is in active labor; she is progressing at this point and we will keep you posted." "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is still in early latent labor and has much too long to go to tell when she will give birth." "She is doing well and is in the second stage; it could be anytime now."

Inability to push

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? A-Dry, cracked lips B-Urinary retention C-Rapid progress of labor D-Inability to push

Continue to monitor the client and the FHR

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? Continue to monitor the client and the FHR Promptly inform the primary care provider Reposition the client Advocate for the client to have a vaginal examination

a possible infection

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: a-normal. b-a possible infection. c-meconium passage. d-transient fetal hypoxia.

Reassuring; it is associated with normal acid-base balance.

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? Reassuring; it is associated with normal acid-base balance. Worrisome; it may be associated with metabolic acidosis. Critical; it represents metabolic acidosis. Damaging; it is frequently associated with fetal neurological damage.

Inform the RN that your client may have ruptured membranes

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and annouces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in? Perform a Fern test Inform the RN that your client may have ruptured membranes Check EFM for late decelerations Perform deep palpation of the client's abdomen

Support the client's decision and call the obstetrician.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? Suggest a less extreme alternative such as a sedative. Support the client's decision and call the obstetrician. Gently remind the client of her goal of a natural birth and encourage and help her. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.

lightening

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: lightening. start of labor. placenta previa. rupture of the membranes.

Assess for labor progression.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first? Assess for labor progression. Prepare the client for an epidural. Assist the client in ambulating to the bathroom. Instruct the client to do slow-paced breathing.

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia? Maternal respirations decrease from 20 to 14 breaths/minute. Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Maternal pulse increases from 78 to 96 beats/minute. Maternal temperature increases from 99° F (37.2° C) to 100° F (37.8° C).

"I may end up with a severe headache from the spinal anesthesia."

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: "I can continue sitting up after the spinal is given." "I may end up with a severe headache from the spinal anesthesia." "The anesthesia will numb both of my legs to a level above my breasts." "I will need to lie on my right side to reduce vena cava compression."

Use a fist to apply counter pressure to the lower back.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? Place the client supine with the head of bed elevated 30 degrees. Use a fist to apply counter pressure to the lower back. Apply a warm washcloth to the lower back. Have the primary care provider administer a pudendal block.

poorly ossified bones of the cranial vault

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? tight membranous attachments poorly ossified bones of the cranial vault rigid bones at the base of the skull well-ossified bones of the face

Change maternal position to an upright or side lying position

A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement? Encourage the Valsalva maneuver. Change maternal position to an upright or side lying position. Administer exogenous oxytocin. Place the client in the lithotomy position.

internal rotation descent flexion

A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply. internal rotation abduction descent pronation flexion

occurring about every 5 minutes

A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: occurring in the abdomen and groin. lasting about 30 seconds. occurring about every 5 minutes. relieved by walking.

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels release of endorphins in response to contractions distraction of the brain cortex by other stimuli blocking of nerve transmission via mechanical irritation of nerve fibers

fetal heart rate declining late with contractions and remaining depressed

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? fetal baseline rate increasing at least 5 mm Hg with contractions variable decelerations, too unpredictable to count a shallow deceleration occurring with the beginning of contractions fetal heart rate declining late with contractions and remaining depressed

Take no extra measures; prepare for a standard labor.

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? Take no extra measures; prepare for a standard labor. Anticipate this client is a one-to-one registered nursing assignment. Notify the client's support person that the labor is typically long. Prepare for vital signs and fetal monitoring hourly.

Meperidine (Demerol)

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control? meperidine thiopental hydroxyzine hydrochloride secobarbital

Position the patient side-lying.

The nurse is concerned that a patient in the second stage of labor will experience a drop in blood pressure. What should the nurse do to prevent this from occurring? Position the patient supine. Encourage oral fluid intake. Administer intravenous fluids. Position the patient side-lying.

Complete cervical dilation and time of fetal birth

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Complete cervical dilation and time of fetal birth Effacement time and time when contractions are regular Time of mucous plug expulsion and full cervical dilation

Change the position of the client.

The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? Administer oxygen. Increase her IV fluids. Change the position of the client. Notify the primary care provider.

acme

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction? acme increment decrement diastole

Assess and reposition the woman.

The practical nursing is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the practical nurse do first? Assess and reposition the woman. Notify the registered nurse. Notify the health care provider. Wait 2 minutes to review another tracing.

Nothing. Normal time for stage three is 5 to 30 minutes.

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Placing a wedge under the hips

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Rubbing the client's legs Placing a wedge under the hips Providing a paper bag Massaging the client's lower back

Vaginal examination

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Urinalysis Vaginal examination Leopold maneuver Nonstress test