Module 4 and 5
A multigravida states to the nurse, "I have to push." The client had a cervical exam less than 10 minutes prior and she was 5/+1/100%. What is the nurse's next action? A. Perform a cervical assessment. B. Encourage the client to pant with contractions. C. Tell the client it is too soon to push. D. Contact the health care provider.
A A multigravida can progress through labor quickly. The head is well applied to the cervix at +1 station. Perform the assessment to determine if she can push. Panting with contraction is good, but it does not evaluate cervical progress. Because the head is down so low, telling the client it is too soon to push may be incorrect information. The HCP will need to be contacted if delivery is imminent.
A client in active labor is 1009% effaced, dilated 3 cm, and at +1 station. Which stage of labor has this client reached? A. First B. Latent C. Second D. Transitional
A The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is no transitional stage of labor; transition is the last phase of the first stage of labor.
Which medication's with the nurse identify as being used to induce labor in pregnant clients? SATA A. Oxytocin B. Ergonovine C. Carboprost D. Misoprotsol E. Dinoprostone
ADE Oxytocin is an oxytocic that triggers or augments uterine contractions; it is used for labor induction. Misoprostol is a prostaglandin used for cervical ripening and labor induction. Dinoprostone is used for cervical ripening to induce labor. Ergonovine is an oxytocic used for postpartum or post abortion hemorrhage. Carboprost is a prostaglandin used to treat postpartum hemorrhage
Twenty-four hours after an uncomplicated labor and birth a client's complete blood count revels a WBC count 17,000/mm. Which interpretation would the nurse assign to this finding? A. A normal, stress- related decrease in WBCs B. A sign of an acute sexually transmitted viral infection C. An expected response to the process of labor and birth D. A manifestation of bacterial infection of the reproduction system
C During the postpartum period, leukocytosis (WBC count of 15,000-20,000) is expected and is related to the physical exertion experienced during labor and birth. A count of 17,000 does not constitute a drop in the WBC count.
The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse that the client is entering stage two of labor? A. "I feel the baby coming out NOW!" B. "I feel like my water just broke." C. "I feel my baby moving around a lot." D. "I feel like I have to push down."
D
Which assessment finding is expected as the transition phase begins? A. Bulging perineum B. Pinkish vaginal discharge C. Crowning of the fetal head D. Rectal pressure during contractions
D Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.
Which is a nonreassuring fetal heart pattern? A. Early decelerations with average variability B. Changes in baseline variability from 5 to 10 bpm C. Increases in fetal heart rate from 135 to 150 bpm with fetal activity D. Variable decelerations that last 60 seconds, then return to baseline tachycardia
D Variable decelerations indicate cord compression; they should return to baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection, or some other factor that is stressing the fetus. Early decelerations and changes on baseline variability are both expected, benign findings. Increases in fetal heart rate with fetal movement are an expected findings
An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn? (Select all that apply.) A. Erythromycin ointment B. Scale C. Vacuum extractor D. Measuring tape E. Blood glucose testing kit
ABDE Erythromycin ointment, a scale, and measuring tape are needed for all deliveries. The neonate is at risk for hypoglycemia after delivery and blood glucose monitoring is necessary. The vacuum extractor may be necessary if the mom is having trouble delivering the infant. However, this piece of equipment is for the mom and not the neonate.
A nurse is monitoring an obstetric client who is in early labor. Which of the following findings would be a cause for concern if observed by the nurse? (Select all that apply.) A. Android pelvis B. Biparietal diameter of less than 9.25 cm C. Vertex presenting part D. General flexion attitude E. Transverse lie
ABE A biparietal diameter at term is typically noted as 9.25 cm, and the finding of a smaller measurement would cause a concern related to the mode of delivery. A transverse lie would also cause a concern relative to the mode of delivery because a cesarean section would be indicated. An android pelvis would cause a concern related to the mode of delivery. A vertex presenting part and a general flexion attitude are normal findings and would not cause concern.
Which statements regarding the involution process are correct? Select all that apply. One, some, or all responses may be correct. A. Involution begins immediately after expulsion of the placenta. B. Involution is the self-destruction of excess hypertrophied tissue. C. Involution progresses rapidly during the next few days after birth. D. Involution is the return of the uterus to a nonpregnant state after birth. E. Involution may be caused by retained placental fragments and infections.
ACD The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.
The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions
ACE These are all signs of true labor. Options B and D are signs of false labor.
The health care provider states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "What does that mean?" What descriptions will the nurse use when teaching the client about the LOA fetal position? (Select all that apply.) A. "The baby's head is in your pelvis." B. "The baby's feet can be felt on your left side." C. "The baby's back is on your right side." D. "That is the ideal fetal birthing position." E. "The baby is looking down towards the floor"
ADE In an LOA position the baby is head down, the occipital bone in in the anterior portion of the maternal pelvis, the fetal back is on the maternal left side, the breech is in the fundus of the uterus and the feet are on the opposite side of the back.
A client in active labor who is 90% effaced, 7cm dilated with the vertex presenting at 2+ station, complains of pain and asks for medication. Which medication would the nurse anticipate causing respiratory depression in the newborn? A. Naloxone B. Lorazepam C. Meperidine D. Promethazine
C Meperidine is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain itself. Promethazine is a tranquilizer, it does not cause respiratory depression or relieve pain.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take next? A. Reapply the external transducer. B. Insert the intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.
D The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.
Which is the best time for the nurse to teach simple breathing and relaxation techniques to a client in labor who has not attended any childbirth classes? A. During the latent phase of the first stage of labor B. During the active phase of the first stage of labor C. During the active phase of the second stage of labor D. During the transition phase of the first stage of labor
A During the latent phase of the first stage of labor the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time between contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the cdient's ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus, and simple breathing techniques are not a appropriate. During the transition phase of the first stage of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.
Which action would the nurse take when a client's membranes rupture while her labor is being augmented with an oxytocin infusion and variable decelerations in the fetal heart rate occur? A. Change the client's position B. Take the client's blood pressure C. Stop the client's oxytocin infusion D. Prepare the client for an immediate birth
A Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord.
Which condition is most commonly associated with late decelerations of the fetal heart rate? A. Head compression B. Maternal hypothyroidism C. Uteroplacental insufficiency D. Umbilical cord compression
C Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable and says she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered? A. Latent B. Transition C. Late active D. Early active
B The physiological intensification of labor that has occurs during transition (8-10cm of cervical dilation) is caused by greater energy expenditure and increased pressure on the abdomen; this results in feelings of fatigue, discouragement, and nausea. The latent phase is the earliest phase of labor. It is characterized by cervical dilation and effacement (0-3 cm). There are three phases in the first stage of labor. The active phase lasts from 4-7cm of dilation. There is no distinction between early and late active phases.
A client is receiving an epidural anesthetic during labor. Which alteration would the nurse recognize as a side effect of the anesthetic? A. Hypertension B. Urine retention C. Subnormal temperature D. Decreased level of consciousness
B Anesthesia blocks the sensory pathways; therefore, the mother does not sense bladder distention and may retain urine and be unable to void. Hypotension, not hypertension, is a side effect of epidural anesthesia. An epidural anesthetic does not influence body temperature. A decreased level of consciousness occurs with general anesthesia, not epidural anesthesia; general anesthesia is used when there is an emergency.
Before discharge, which suggestion would the nurse give to a nonnursing mother to help limit breast engorgement? A. Place raw cabbage leaves over the breast. B. Stop drinking milk for 1 week C. Take an analgesic every 4 hours. D. Apply warm compresses to the breasts.
A Fresh, raw cabbage leaves placed over the breasts can help relieve engorgement. It is thought that the effect of the cabbage leaves is related to the coolness of the leaves and the presence of phytoestrogens. Engorgement lasts about 3 to 5 days. Milk and fluids should not be restricted during the postpartum period. Medication will ease pain; however, it will not limit further engorgement. Application of warm compresses may enhance milk secretion rather than suppressing it. Cold compresses will limit further engorgement in the nonnursing mother. Large bags of frozen peas make easy ice packs.
The nurse is providing care for a woman who just delivered. The umbilical cord extends from the vagina accompanied by a gush of blood. What is the next nursing action? A. Massage the fundus. B. Take the mother's blood pressure. C. Place a straight catheter. D. Assign the second Apgar score.
A These are signs that the placenta has separated from the uterus. Implement interventions that would promote the uterus to contract, such as massaging the fundus or placing the infant to breast. If oxytocin is in use, the health care provider may prescribe a rapid infusion of oxytocin. This is a normal finding with the delivery of the placenta. The increase in blood volume with pregnancy accommodates this gush of blood and therefore the blood pressure will not be impacted. There is no indication in the normal scenario that a catheter is indicated. It can take up to 30 minutes for the uterus to release the placenta. The second Apgar needs to be assessed at 5 minutes after birth.
While caring for a client during labor, which would the nurse remember about the second stage of labor? A. It ends at the time of birth B. It ends as the placenta is expelled C. It begins with the transition phase of labor D. It begins with the onset of strong contractions
A The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor after birth, continues until the separation of the placenta from the uterine wall, and ends with expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occur during the active phase of the first stage of labor
A nurse is reviewing the onset of labor. Which sign should the nurse identify as not preceding the onset of labor? A. A decline in energy, as the body stores up for labor B. Stronger and more frequent uterine (Braxton Hicks) contractions C. A return of urinary frequency as a result of increased bladder pressure D. Persistent low backache from relaxed pelvic joints
A A surge of energy is a phenomenon that is common in the days preceding labor. After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Prior to the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength; bloody show may be passed.
Which statement by the lactating client indicates that further teaching about solutions for breast engorgement is needed? A. "I will manually express breast milk" B. "I will breast-feed the infant less frequently." C. "I will apply warm compresses to both breasts." D. "I will place cold compresses on my breasts just after breast-feeding
B Frequent nursing empties the milk ducts, relieving engorgement. Manual expression initiates milk flow, empties the ducts, and relieves engorgement. Warmth will dilate ducts and facilitate flow of milk, relieving engorgement. If the breasts remain engorged immediately after breast-feeding, cold compresses help relieve the discomfort.
The nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. Which other parameter can the nurses to estimate but my boss in a postpartum client? A. Odor of the lochia B. Color of the lochia C. Presence of small clots on the pad D. Time elapsed between pad changes
D Knowing the time elapsed between pad changes will help the nurse quantify The blood loss. Postpartum hemorrhage may occur after the third stage of labor or during the first 24 hours postpartum; Hemorrhage is defined as a blood loss in excess of 500 ML. The best estimation of blood loss takes into consideration a combination of factors, including degree of saturation of perineal pads and frequency of pad changes. The nurse must also assess whether there is pooling of blood under the buttocks. Odor will reflect the possible complication of infection, not hemorrhage. The color of vaginal discharge at this time will not indicate hemorrhage. The color of the lochia during the first postpartum day is expected to be red (rubra) The presence of clots is common and is not an indicator of the amount of blood loss
Which fetal heart tracing during labor can most likely result in fetal hypoxia and metabolic acidosis? A. Accelerations B. Variable decelerations C. Fetal heart rate variability D. Recurrent late decelerations
D Recurrent late decelerations can most likely result in hypoxia and metabolic acidosis.
A nurse is caring for a patient in labor. Which observation by the nurse would indicate that the second stage of labor, the descent phase, has begun? A. The presenting part is below the ischial spines. B. The amniotic membranes rupture. C. The woman experiences a strong urge to bear down D. The cervix cannot be felt during a vaginal examination.
D. The second stage of labor begins with full cervical dilation. During the active pushing phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as at 5 cm dilation.
A nurse is taking care of a client in the third stage of labor. Which statement should the nurse identify as correct? A. The duration of the third stage may be as short as 3 to 5 minutes. B. The major risk for women during the third stage is a rapid heart rate. C. The placenta eventually detaches itself from a flaccid uterus. D. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.
A The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage; the risk of hemorrhage increases as the length of the third stage increases.
An epidural anesthetic is planned for the adolescent in labor. Which nursing interventions are essential before epidural anesthesia is administered? Select all that apply. One, some, or all responses may be correct. A. Performing a baseline vaginal examination B. Telling the adoleșcent what to expect with each procedure C. Identifying risk factors that contraindicate epidural anesthesia D. Having the parents sign a consent form for the epidural anesthesia E. Explaining the need to stay in one position while the epidural catheter is in place
ABC A baseline vaginal examination is needed to determine the extent of cervical dilation and effacement. Before any procedure is implemented, the nurse should explain the procedure and answer any questions. Risk factors that contraindicate epidural anesthesia include antepartum hemorrhage, bleeding disorders, and allergy to the medication. None of these conditions is indicated in the client's history. Although a signed informed consent is legally required for this invasive procedure, the adolescent, not the parents, should sign the consent; a pregnant woman is considered an emancipated minor and is legally empowered to sign the consent. The client should change position from side to side every hour to promote distribution of the anesthetic and to maintain circulation to the uterus and placenta.
A primigravida at term presents to the labor and delivery unit smiling and states to the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes are intact. Maternal vital signs are stable. What are the nursing actions for this phase/stage of labor? (Select all that apply.) A. Encourage the mother to ambulate. B. Have the mother use slow, deep breathing with contractions. C. Encourage the mother to urinate every 1 to 2 hours. D. Assess the fetal heart tones every 15 minutes. E. Assess for cervical dilation every hour.
ABC The client is in the latent phase of the first stage of labor. Ambulation will encourage fetal descent. The contractions are mild in this phase and deep chest breathing will help facilitate relaxation. Urination will help keep the pelvic area evacuated, to promote fetal descent. Fetal heart tones are assessed every 30 to 60 minutes, depending on the protocol of the birthing facility. Frequent assessment of cervical dilation can introduce infection. Cervical dilation should only be performed as needed.
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a bowel movement yet." What are the nurse's recommendations for this client? (Select all that apply.) A. "Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per day." B. "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears." C. "Increase the frequency of breast-feeding to no less than every two hours." D. "Since it is nice outside, take a 15-minute walk two to three times a day." E. "Take your narcotic pain medications as prescribed, every 3 to 4 hours.
ABD For post-partum constipation, drink at least 2000 mL of water every day. Eating foods high in fiber will help with constipation. Ambulation also helps with constipation. Increasing the frequency of breastfeeding helps with uterine involution, but not with constipation. Frequent use of narcotic pain medication can be constipating.
Although a client in labor is prepared and plans to participate in the labor birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol. Which phase of labor is the safest time for the nurse to administer butorphanol? A. Early phase B. Active phase C. Transition phase D. Expulsion phase
B Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours. The level of pain during the early phase can usually be managed with other strategies such as breathing techniques or diversion; giving an opioid early in labor may slow the progress of labor. An opioid should be avoided in the 2 hours preceding birth; giving it to a client in the transition phase can cause respiratory depression in the newborn. Giving the medication when birth is imminent is contraindicated because it may cause respiratory depression in the newborn; the mother's LOC will be altered as well, making it difficult for her to cooperate with requests for her to push
The laboring client requests an epidural placement for labor pain. The standing order is for 1000 mL of LR to infuse over 15 minutes prior to the placement of the epidural. The client asks, "How come I have to have so much fluid so fast?" What is the nurse's best response? A. "It is to prevent supine hypotension." B. "It is to help prevent low blood pressure." C. "It is to ensure adequate oxygenation to just your brain." D. "It will help you keep cool during epidural placement."
B With epidural placement, vascular relaxation can occur with subsequent hypotension. Increasing the fluid volume can help place increased tension on the vascular space, and combat the possible hypotension with the placement of an epidural. Supine hypotension occurs when the weight of the fetus is on the vena cava, resulting in hypotension. Hypotension can cause a decrease in oxygen to all of the major organs, and to the fetus. An increase in fluid volume is not related to if a client feels warm or cool.
The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.) A. Erythromycin ophthalmic ointment B. Amnihook C. 1000 mL of D5LR D. Oxytocin E. Blankets
BCD This client is having irregular contractions and is at risk for a dysfunctional labor. Since the head is a 0 station, an amniotomy may help facilitate the progress of labor. Also, to help with the progress of labor, the client may need hydration and augmentation with oxytocin. This client's labor may progress quickly once a regular contraction pattern is established; however, birth is not imminent which would require the ointment and the blankets.
The clinic nurse is reviewing phone messages left from postpartum clients during the lunch break. Which calls will the nurse return before the others? (Select all that apply.) A. The mother who reports her baby who is having trouble latching on to her breast while feeding. B. The mother who reports her vaginal discharge went from brown to bright red. C. The mother who reports her vaginal flow smells "like a chicken farm." D. The mother who reports she had sex before her six-week check-up. E. The breast-feeding mother who reports redness and a painful right breast.
BCE Vaginal discharge should go from red to brown to white. Recurrence of bright red blood is an indication to be seen by her health care provider. Postpartum vaginal flow should have the same odor of menstrual flow. A foul smell indicates a uterine infection. Painful, unilateral and red breast is an indication of mastitis. As these reports present a concern for maternal health, these are the priority calls to return. Trouble latching on may need a consult by the lactation nurse. Having sex before the six week check-up may pose a risk for infection. There were no reported signs of infection from the caller, which decreases the urgency of the return call.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)
C The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.
Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Increase the IV fluids. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D. Assess for cervical dilation.
C The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful to increase vascular space but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description should a nurse indicate as being accurate with regard to the phases of the first stage of labor? A. Lull: no contractions; dilation stable; duration of 20 to 60 minutes B. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours C. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours D. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours
C The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.
and the client becomes nauseated and irritable. Which phase of labor would the nurse Soon after a vaginal examination revealing cervical dilation of 8 cm, bloody show increases conclude the client is entering? A. Latent B. Active C. Transition D. Early active
C The transition phase is the most difficult phase of labor. Characterized by restlessness, irritability, nausea, and increased bloody show, it continues from 8 to 10 cm of dilation. The latent phase is early labor (1-4 cm of dilation). It is relatively easy to tolerate, and the client generally is in control and not too uncomfortable. The active phase lasts from about 4 to 6 cm of dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show. The early active phase lasts from about 4 to 6 of cm dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which actions should the nurse take immediately? (Select all that apply.) A. Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D. Increase the rate of the main line IV. E. Place oxygen by facemask. F. Turn off the continuous epidural.
CDE The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. What is the next nursing action? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin infusion.
D The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.
The nurse is providing care to a client who just delivered her sixth term infant. In addition to routine postpartum care, what additional priority nursing action will the nurse include in this client's plan of care? A. Use warm water in the peri bottle to cleanse the peri area after birth. B. Perform fundal assessments every 15 minutes for the first hour after delivery. C. Bring the siblings in to see the newborn at two hours after delivery. D. Weigh the peri pads before and after placement to the peri area.
D This client is at risk for postpartum hemorrhage (PPH). One gram of blood equals one mL of blood loss. Pre and post weighing the peri pad will give a better estimate of blood loss (EBL) after delivery. Warm water to the peri area is a comfort measure, but not as important as the EBL. Fundal massage for this client should be more frequent than every 15 minutes as she is at risk for PPH. Sharing time with siblings is psychosocial; physical needs take priority over psychosocial needs.
