Maternity: Chpt. 14

A pregnant client at 32-week gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

headache following anesthesia

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification?

"The client reports a pain level of 8. She has a low pain tolerance."

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next?

Notify the health care provider

A woman is admitted to a labor unit in active labor. Which assessment would alert you to the possibility that she may have difficulty accepting this child?

"I want this baby to be a boy."

A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?

"It relieves pressure on the fetal head."

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used.

(-4); (-2); (0); (2); (4)

A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural?

Administer a fluid bolus through the IV line to reduce the risk of hypotension

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

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

Assess vital signs

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?

Change the position of the client

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?

Clear to straw-colored fluid

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

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute

The nurse is performing Leopold's maneuvers as part of the initial assessment. Which action would the nurse do first?

Feel for the fetal buttocks or head while palpating the abdomen

How does a woman who feels in control of the situation during labor influence her pain?

Feelings of control are inversely related to the client's report of pain

The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication?

Inability of the immature liver to metabolize or inactivate drugs

Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first?

Turn onto the left side or raise the legs

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.

The nurse is providing preoperative care for a client who will undergo a cesarean section. The nurse should:

confirm that consent has been provided by the client

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness

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

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia

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?

naloxone

The injection of a local anesthetic to block specific nerve pathways is referred to as

regional block

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

uterine atony

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the woman to push when she has a strong desire to do so

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?

10:30 a.m.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?

Ambulate only with assistance from the nurse or caregiver

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?

Anxiety can slow down labor and decrease oxygen to the fetus

A pregnant patient planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor?

Any medication should have maximum effect for the patient and minimal effect on the fetus

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?

Continuous support through the labor process helps decrease the need for pain medication

A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method?

Counterirritation stimulation blocks pain from traveling to the spinal cord

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?

Fetal status

Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor?

Interference with blood coagulation with increased risk of bleeding in mother or infant

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

Maternal tachycardia and falling blood pressure

The nurse is preparing materials to instruct a pregnant patient about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the patient?

Regional anesthesia

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?

Support the client's decision and call the obstetrician

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

This is a technique to prevent the painful stimuli from entering the brain

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency?

every 15 minutes

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

frequency, intensity, and uterine resting tone

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

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. It would be most appropriate to meet which criterion?

rupture of membranes

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern

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?

110 to 160 bpm

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?

Effleurage

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Meconium in the fluid

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?

"Spinal headache is not a usual complication of epidural blocks."

The spouse of a pregnant patient is concerned about the risk of paralysis from an epidural block being used during labor. How should the nurse respond to the spouse's concern?

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

A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

Ask the client to describe the intensity of her pain on a scale of 0 to 10

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask.

A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?

Before reporting to the RN, determine the uterine contraction pattern

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?

Practicing effleurage on the abdomen

When entering the second phase of labor, a patient tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the patient at this time?

Decision conflict related to the use of analgesia during labor

Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms?

Electrical impulses are created that interfere with nerve transmission

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR

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?

Inability to push

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "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?

Inform the RN that your client may have ruptured membranes

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?

Initiate the technique only when the client is in active labor

A multigravida client admitted in active labor has progressed well and the client ane fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?

Inspect the perineum

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?

Palpate the area just above the symphysis pubis

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?

Provide care under the supervision of an RN

When developing a labor plan with the client, which outcome is the priority?

The client will direct her pain management techniques

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions

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

acme

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate