Maternal newborn/ Peds Test 3 study guide

Differentiate between early, variable, and late decelerations. What are they caused by and what would the nurse see on the fetal monitor?

-4 categories of variability: absent, minimal, moderate, & marked-Normal irregular changes & fluctuations in FHR Baseline rate should vary 10-15 bpm Tracing appears as a jagged line Variability is indicative of mature fetal neurologic system Early: Caused by vagal simulation from head compression, & is reassuring pattern that may be prevented by avoiding early rupture of membranes Begins at or after onset of contraction & returns to baseline rate by time contraction has finished & produces mirror image of contraction Not sign of fetal problems2nd stage of labor. Late: Begins after onset of peak or middle of contraction & ends after contraction Begins during or after contraction & has not recovered by time that contraction has ended Indicates decreased blood flow during uterine contraction Persistent late decelerations are ominous, especially if decelerations are uncorrectable, & if associated with absent or minimal variability & tachycardia Variable: Unrelated to contractions Caused by umbilical cord compression May appear V-shaped or U-shaped or W-shaped As many as 50% of all monitored babies experience variable decelerations during labor If baseline FHR remains stable & variability remains good, variable decelerations are not associated with poor fetal outcome Indicate possible compromise if they become prolonged or are persistent Most commonly occur during transition & 2nd stage of labor A. Early decelerations caused by head compression B. Late decelerations caused by uteroplacental insufficiency C. Variable decelerations caused by cord compression

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? At the symphysis pubis 1 cm above the umbilicus At level of umbilicus 1 cm below the umbilicus

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

What are the normal physiologic changes that occur with a postpartum mom?

1) Uterus- goes back to pre pregnancy size, continues to contract to compress the blood vessels to stop bleeding, after pains of uterus contracting and relaxing due to pitocin and breastfeeding, regenaration of placenta site, lochia is uterine discharge expelling blood, tissue debris, WBC, bacteria, fluid. 2)cervix- decreases to size, loses circular shape and appears as a jagged slit described as a "fish mouth". 3) Vagina and perineum: thin and dry , goes back to normal after breastfeeding and starting the menstrual cycle and rugae will never be as pre pregnancy state .4) Abdomen: about six weeks for the abdomen to return to almost pre pregnancy state. 5)Placental hormones: rapid decrease in human chorionic somatomammotropin (human placental lactogen), estrogens, cortisol, and placental enzyme insulinase. So, results in decreased lower blood glucose levels. Decreased estrogen levels lead to breast engorgement and pueperium diuresis. Non lactating estrogen increase in 2 weeks. Breastfeeding estrogen increases by day 17 postpartum. Human chorionic gonadotropin disappears from moms circulation in 14 days. 6) Pituatary hormones and Ovarian function: Breastfeeding increase prolactin and maintain high. Non lactating women prolactin levels decrease by day 3 to 4. Ovulation occurs about day 27 with a mean time of 10 weeks for nonlactating. Breastfeeding mothers ovulation occurs at about 6 months. 7) Urinary system: glycosuria disappears, lactosuria appears in lactating mothers, blood urea nitrogen increases from autolysis of the involuting uterus. +1 proteinuria for 1 to 2 days postpartum due to excess protein due to uterine muscle breakdown. Ketonuria may happen due to uncomplicated labor or after a prolonged labor with dehydration. Postpartal diuresis within first 12 hours last about 2 to 3 days due to low estrogen levels and body excreting excess water weight due to pregnancy. Urethra and bladder have a less feeling to void to do birth trauma, anesthesia, increased bladder capacity during birth, laceration, episiotomy, soreness. 8) gastrointestinal system: mom is very hungry after birth. Bowel evacuation may not occur up to 2-3 days after birth. Due to decreased muscle tone in the intestines, prelabor diarhhea, lack of food, or dehydration. Perineal tenderness, hemorroids, laceration. Due Kegels 9)Breasts: colustrum first then true milk (72-96 hrs after) feel nodular or lumpy. Nodules shift in position. breast engorgement last 24-48 hrs.nonbreastfeeding: nodular, colustrum, third day engorgement, . discomfort resolves 24-36 hrs after. 10) Cardiovascular system: blood volume decreses, pulse rate, stroke volume, cardiac output increases through pregnancy. each component remain elevated over nonprenant values for 12 weeks after birth and may not stabilize until 24 weeks after birth. 11) Neurologic system: pregnancy induced neurologic disconforts disappear after birth. Carpal tunnel syndrome is relieved and periodic tingling and numbness disappears . Headaches need to assessed throughly. 12) Musculoskeletal system: Back to pre pregnancy state . may have bigger feet especially parous women. 13) Integumentary system: Chloasma disappears, hyperpigmentation of the areola and linea negra may not completely disappear. Spider angiomas(nevi), palmer ertythma, epulis will regress due to low estrogen levels. For some nevi will not disappear. Striae gravidarum usually does not disappear. Hair growth slows, fingernail back to prepregnancy state. Profuse diaphoresis is the most noticeable change postpartum. 14) Immune system- no changes, some vacinations like rubella and rhogam to prevent Rh isoimmunization .

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

8 to 10 Explanation: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? 40% 85% 25% 100%

85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Preform a vaginal exam

A

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? A. "The injection is given in the space outside the spinal cord." B. "I have never read or heard of this happening." C. "An injury is unlikely because of expert professional care given." D. "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

A R: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

The nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based of the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. The client is exhibiting manifestations of the following? (SATA) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia

A, B, D

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

Ask the woman to describe why she believes that she is in labor. Explanation: The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as the client may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not the client is in labor. The client may be in false labor, and more information should be obtained before the client is brought to the hospital.

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs.

What's happening during the fourth stage of labor? What's the nurse assessing? What are we trying to prevent?

Assessments are happening and we are assessing the uterus. Every 15 minutes the first hour. Making sure the uterus is shrinking back down.

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking. Explanation: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response? A. "Your health care provider knows what is best for you." B. "The pain relief offered will compensate for the discomfort afterward." C. "Spinal headache is not a usual complication of epidural blocks." D. "The anesthesiologist will do her best to avoid this."

C R: Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

differentiate fetal positions/presentation (cephalic, breech, shoulder) and what type of delivery would be best for each one.

Cephalic- head down with face facing moms back. Best position and vaginal delivery is best Breech- Anything but the head is facing down first. Could have cord prolapse and vaginal birth becomes dangerous. Shoulder- Baby's shoulders are stuck on moms pelvis.

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

D R: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

A nulliparous client at 37 weeks gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?

Contraction, regular and lasting longer and stronger Explanation: True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?A. Administering an opioid such as meperidine or fentanyl B. Immersing the client in warm water in a pool or hot tub C. Administering a sedative such as secobarbital or pentobarbital D. Practicing effleurage on the abdomen

D R: In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

Know "after pains"

Cramp like pains due to contractions of the uterus that occur after childbirth. They are more common in multiparas, tend to be most severe during breastfeeding, and last 2 to 3 days The nurse is aware that afterpains are more common in multiparas and are worsened with the administration of oxytocin and pitocin. Thus, when breastfeeding the release of oxytocin causes the afterpains to be more intense. The nurse can administer a mild analgesic agent about 1 hours before breastfeeding or place a warm water bottle to the lower abdomen to reduce the discomfort of afterpains.

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR variability D. Relaxation between uterine contractions

D

The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor? A. Water therapy B. Hypnosis C. Patterned birthing D. Attention focusing

D R: Attention focusing is the use of an object or picture or image for the woman to reflect and focus on (internally or externally) during labor to distract her from the labor pain. Hypnosis is a psychological state. Water therapy involves the woman sitting in water to relax. Patterned breathing involves the woman controlling her breathing patterns during contractions and "breathing through" them to help control the pain. The attention focusing, patterned breathing, water therapy, and hypnosis are all variations of relaxation which may be used by the client during the birthing process.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? A. every 20 minutes B. every 10 minutes C. every 5 minutes D. every 15 minutes

D R: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? A. Anxiety will increase blood pressure, increasing risk with an epidural. B. Increased anxiety will increase the risk for needing anesthesia. C. Decreased anxiety will increase trust in the nurse. D. Anxiety can slow down labor and decrease oxygen to the fetus.

D R: Out of control anxiety can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and can have a negative impact on the fetus by decreasing the amount of oxygen reaching the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural or the need for anesthesia. Trust in the nurse is not determined by the amount of anxiety the client experiences.

Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first? A. Place the patient supine. B. Ask the patient to take deep breaths. C. Raise the head of the bed. D. Turn onto the left side or raise the legs.

D R: To help prevent supine hypotension syndrome, place the pregnant patient on the left side after an epidural block. If hypotension should occur, the patient's legs should be raised in addition to providing oxygen, intravenous fluids, and medication. The supine position encourages hypotension syndrome. Raising the head of the bed and deep breathing are not interventions to help with hypotension syndrome.

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Excessive oxytocin Mastitis Engorgement Blocked milk duct

Engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Encourage the mother to breast-feed to help relax the uterus. Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain.

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

What fetal response is the nurse monitoring when a woman is in labor?

Fetal heart rate

boggy fundus

Fundus is boggy when it is not firm, may indicate hemorrhage. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP hemorrhage. Massage the boggy fundus to stimulate it to become firm again, or give patient Pitocin, or have the patient breastfeed.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? Try to avoid carrying the baby for a few days. Maintain correct posture and positioning. Apply ice to the sore joints. Soak in a warm bath several times a day.

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? Evolution Involution Decrement Progression

Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

Negative side affects associated with Opiods as pain management for laboring mom?

Opioids don't completely eliminate labor pain and typically don't work for pain experienced during delivery. They commonly cause nausea, vomiting and drowsiness. These medications can affect your newborn's breathing and cause your baby to be drowsy, which might interfere with initial breast-feeding.

The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Notify a primary care provider. Apply a warm washcloth. Put on a witch hazel pad.

Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA Explanation: The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front Explanation: Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

If a child has bacterial pneumonia, what s/s would indicate the need to be hospitalized?

Shortness of breath, grunting, retractions, extremely Low pulse o2 below 90, any sign that they are not oxygenating well or showing signs of respiratory distress, poor oral intake, tachypnea, lethargy

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.

A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (SATA) A. ''It is considered a noninvasive procedure?" B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."

B, D, E

A nurse is caring for a client who is in active labor, irritable and reports the urge to have a bowel movement. The client vomits and states "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A. Second stage B. Forth stage C. Transition phase D. Latent phase

C. the transition phase of labor occurs when the client becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis.

A nurse is caring for a client who is 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. Examine the amniotic fluid for meconium B. Check the FHR C. Dry the client and make them comfortable D. Apply a tocotransducer

B. The greatest risk to the client and the fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action to take is to check FHR for clinical findings of distress.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell."

"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the doctor needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul smelling both indicate a possible infection and the doctor needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two. "A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely."Explanation:Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? A. less anxiety B. decreased sedation C. increased cervical dilation D. increased feelings of control

A R: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor

The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? A. Help the client regain control of her breathing technique. B. Notify the RN that client's blood pressure has increased. C. Notify the RN about the lack of FHR variability. D. Assist the client into a hands-and-knees position.

A R: The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is not improvement, notify the RN. Putting the patient in the hands-and-knees position should be avoided until later in labor.

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? A. Ambulation ad lib B. Complete bed rest C. Bathroom privileges D. Up in chair TID

A R: To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

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? A. ischial spine B. pubic symphysis C. cervical os D. ischial tuberosity

A R:Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as zero station.

A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 min, The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? A. Pudendal B. Epidural C. Spinal D. Paracervical

A. a pudendal block is a transvaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy and repair and the expulsion of the fetus.

A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor

A. in the stage 1, latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds.

Differentiate postpartum baby blues, depression, and psychosis.

Baby blues- Mild depressive symptoms, anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue Usually peak at days 4 and 5 and resolve by day 10 Depression-Symptoms last longer and are more severe and require treatment May lead to poor bonding, alienation from loved ones, daily dysfunction, and violent thoughts/actions

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluid which of the following statements should the nurse make? A. "It is needed to promote increased urine output." B. "It is needed to counteract respiratory depression." C. "It is needed to counteract hypotension." D. "It is needed to prevent oligohydramnios."

C. Maternal hypotension can occur following an epidural block and can be offset by administering an IV fluid bolus.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? Assist the woman into the shower, and have her run cold water over her breasts. Assist the woman in placing ice packs on her breasts. Explain to the woman that she should breastfeed because she is producing so much milk. Ask if she wants a breast pump to empty her breasts.

Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.

Postpartum priority assessments

B - BREAST U - UTERUS B - BLADDER B - BOWEL L - LOCHIA E - EPISIOTOMY EXTREMITIES/EMOTIONAL/EDUCATION

A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios

B rupture of the membranes for longer than 24 hr prior to delivery increases the risk that infectious organisms will enter the vagina and then eventually into the uterus

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? A. A quick epidural can replace the need for pain medication. B. Continuous support through the labor process helps decrease the need for pain medication. C. Sitting in a hot tub helps decrease the need for pain medication. D. Lying on an ice pack can help decrease the need for pain medication.

B R: Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication.

The nurse is providing a report on a gravida 3 para 2 client. The nurse states that the client is fully effaced, 7 cm dilated, station +1, and contractions every 8 minutes. Which nursing action is most important at this time? A. Discuss contraction intensity. B. Record tocodynamometer readings. C. Obtain vital signs. D. Ambulate the client in the hall.

B R: From the report, it is understood that the client's labor is progressing. The most important nursing action at this time is to assess how the fetus is tolerating the labor process via the tocodynamometer. The nurse would also obtain vital signs and discuss pain management and contraction intensity. Depending upon the progression of the labor and how the client is feeling, the client may not ambulate in the hall.

The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper? A. Pink B. Blue C. Yellow D. White

B R: If the fluid in the vaginal canal is amniotic fluid, the Nitrazine paper will turn a dark blue, the color of an alkaline fluid, and this is a positive Nitrazine test for rupture of membranes.

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication? A. epinephrine B. naloxone C. indomethacin D. ampicillin

B R: Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor

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

B R: The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.

A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated? A. "I would like the baby's father to cut the umbilical cord." B. "I will remain in my bed for my labor and birth like last time." C. "We will hire a doula for our labor support." D. "My 6-year old son will be in the birthing room, too."

B R: The nurse should educate the client that she will be encouraged to get out of bed during labor. In the labor and birth process, many positions, ambulation, and water therapy may be used for comfort and positioning. All other answers are appropriate client responses.

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? A. Emotions are calm and happy. B. The urge to push occurs. C. Frequency of contractions are 5 to 6 minutes. D. Fetus is at -1 station.

B R:Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? A. 100 to 150 bpm B. 110 to 160 bpm C. 90 to 140 bpm D. 120 to 170 bpm

B R:The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized? A) Fever B) Oxygen saturation level of 96% C) Tachypnea with retractions D) Pale skin color

C Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can be successfully managed at home if the work of breathing is not severe and oxygen saturation is within normal limits. Hospitalization would most likely be required for the child with tachypnea, significant retractions, poor oral intake, or lethargy for the administration of supplemental oxygen, intravenous hydration, and antibiotics. Fever, although common in children with pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions; this finding also would not necessitate hospitalization.

A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? A. Alert the team that internal fetal monitoring may be needed. B. Encourage the client to push. C. Palpate the area just above the symphysis pubis D. Institute effleurage and apply pressure to the client's lower back during contractions.

C R: Palpate to determine if the infant is engaged and what the presenting part of the infant is by the symphysis pubis; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.

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? A. Greenish fluid B. Bloody fluid C. Clear to straw-colored fluid D. Cloudy white fluid

C R: The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign? A. "This means +1 and the baby is entering the true pelvis." B. "This indicates that you start labor within the next 24 hours." C. "The presenting part is at the true pelvis and is engaged." D. "This is just a way of determining your progress in labor."

C R:Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

A client calls a provider's office and reports having contractions for 2 hours that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions

D True contractions don't go away with hydration or walking. They are regular in frequency, duration, and intensity and become stronger with walking.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage Gently massage the fundus until it tones up

Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

Understand hydrotherapy

Have to be farther than 37 weeks, baby is not in distress, no pain medications/opioids, and no IV lines

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her hematocrit Her episiotomy

Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.

Care for a mom receiving an epidural

Hold her still and comfort her

What happens to the fetus skull as it passes through the birth canal?

Molding- This process allows the skull sutures to overlap and change shape.

What is priority for the nurse to assess once mom's membranes have ruptured

Time of rupture; whether rupture was spontaneous or artificial; quantity of fluid; fetal heart rate (FHR) for at least 1 minute; color of fluid (clear, possibly with bits of vernix, is normal; green indicates fetal meconium passage; yellow or cloudy suggests infection); odor (foul or strong odor suggests infection)

What are the true labor signs? False labor signs?

True Labor- Cannot talk through contractions, contractions are consistent and timely False Labor- Can talk through contractions, contractions will stop if doing certain activities

What are normal physiologic changes that occur in laboring women (especially in regards to Vitals signs and lab values)

We expect her temperature, HR, RR, BP, and WBC to elevate.

A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing. Apply warm compresses.

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

Know how to teach lactation suppression

Wearing a supportive, well-fitting bra within six hours after delivery. Avoid bras with underwire. A sports bra works well. Minimizing stimulation to the breasts. Avoid extended warm showers. Placing ice packs on your breasts and underarms for comfort and to reduce the swelling. Frozen packs of peas or corn work well, as they conform to the shape of your breast. Be sure to wrap ice packs or frozen veggies in a thin towel or other cloth to protect your skin. Taking ibuprofen if you're not allergic to it. It often can relieve pain and reduce swelling. Expressing just enough milk to relieve the pressure if your breasts become too uncomfortable. Over-pumping can cause your breasts to make more milk. Using nursing pads for milk leakage, if needed. Avoiding excessive salt intake.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues? a 29-year-old mother who has lots of family visiting and offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 38-year-old G1 P1 who is constantly holding the baby and touching the baby's hands and fingers

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding During the postpartal period many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartal blues. The 38-year old-mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia rubra a scant amount of lochia serosa a moderate amount of lochia alba

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

What characteristics of amniotic fluid are normal and abnormal?

clear normal, cloudy, green

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?

decrease in circulation and perfusion to the fetus When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement Explanation: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilatation refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

Differentiate between engorgement and mastitis.

engorgement is fullness of breast mastitis is inflammation of breast (with or without infection)

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? progesterone hCG prolactin estrogen

estrogen The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis.

What is prolonged rupture of membranes and what are we concerned about?

greater risk of infection

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inadequate secretion of prolactin improper positioning of infant cracking of the nipple inability of infant to empty breasts

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

increase even if relaxing and taking a shower Explanation: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in heart rate increase in blood pressure increase in respiratory rate Explanation: When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

Differentiate between the different stages of labor, including the three phases within the first stage. Given a scenario, what stage and phase would the mom be in?

o 1st Stage- Dilation of cervix § Latent phase- 0-3cm dilated; contractions 5-10 minutes apart § Active phase- 4-7cm dilated; contractions 2-4 minutes apart § Transition phase- 8-10cm dilated; contractions 1 minute apart o 2nd Stage- Delivery of baby o 3rd Stage- Placenta expulsion o 4th Stage- 1-4 hours following delivery (watching for hemorrhage)

Find the Station

o Above the ischial spine is negative o In line with the ischial spine is 0 o Below the ischial spine is positive

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput Explanation: with a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

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 about every 5 minutes. Explanation: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the women evaluated, especially if she is less than 38 weeks pregnant.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?

shoulder Explanation: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up toward the face. Explanation: In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.

thrombophlebitis

thrombophlebitis, thrombus associated w/ inflammation

A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?

transverse (biparietal)Explanation: The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet, so the best presentation for birth is when the fetus presents a transverse (biparietal) diameter (the narrowest fetal head diameter, at 9.25 cm) to this. The other diameters of the fetal skull that are listed are all larger.

During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition? postpartum diaphoresis urinary tract infection uterine atony urinary retention

uterine atony Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.