Ob 15

ferning

Characteristic appearance of dry amniotic fluid when viewed under a microscope

Why is it important to place a small pillow under one hip if the mother must lie briefly on her back?

To prevent supine hypotension from aortocaval compression by the heavy uterus

List the two nursing priority determinations when a woman enters a birth center

Condition of the mother and fetus; nearness to birth

The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetus is active during the initial assessment. Fetal heart rate is 135 to 150 bpm, and the rate often accelerates. Amniotic fluid is light green with small white flecks in it. Vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis. What stage (and phase, if applicable) of labor is Erin in?

Active phase of first-stage labor

crowning

Appearance of the fetal presenting part at the vaginal opening

Erin complains of back discomfort during each contraction. What interventions might make this discomfort more tolerable?

Assuming any of several upright positions and leaning forward during contractions; hands and knees; firm sacral pressure

What maternal vital signs might indicate problems?

Blood pressure, 140/90 mm Hg or higher Temperature, 38° C (100.4° F) or higher

Describe how contractions feel to the nurse when palpated if they are moderate

Can be indented, but with more difficulty like the chin

The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetus is active during the initial assessment. Fetal heart rate is 135 to 150 bpm, and the rate often accelerates. Amniotic fluid is light green with small white flecks in it. Vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis. What is the fetal presentation and position?

Cephalic; right occiput posterior (ROP)

After 4 hours of labor in the birth center, Erin's cervix is completely dilated and effaced, and the fetal station is 11. Erin feels the need to push during some contractions. What is the safest way to advise Erin to push?

Delayed pushing may be encouraged until Erin has a more intense urge to push. When Erin pushes, she should avoid prolonged breath-holding. She can be taught to take a deep breath and exhale it and then take another deep breath and push for 4 to 6 seconds at a time while exhaling. A final deep breath at the end of the contraction helps her relax

Why is a woman's previous adverse reaction to dental anesthesia relevant to birth?

Dental anesthesia is related to many of the local anesthetic agents used in regional and local anesthetics such as epidurals

What nursing assessments are needed to observe for hemorrhage?

Firmness, height, and position of the uterine fundus, vital signs, amount of lochia, and observing and intervening for a full bladder help prevent hemorrhage caused by the bladder's interference with uterine contraction

Describe how contractions feel to the nurse when palpated if they are strong

Little indentation is possible; woody feel; like the forehead

pH test

Paper or swab used to detect ruptured membranes

Erin is an 18-year-old primigravida who calls the intrapartum unit because she thinks that she might be in labor. What information should the nurse obtain to help determine whether Erin is in true labor?

Regular contractions that have increased in duration, intensity, and frequency suggest true labor. Irregular contractions and those that do not intensify suggest false labor. In addition, discomfort is usually felt in her back or sweeping around to her lower abdomen. Erin should be instructed to come to the birth center if she thinks that her membranes may have ruptured, even if she is not having contractions

When pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head, it is termed the _______________

Ritgen maneuver

funic souffle

Sound of blood going through the umbilical cord

uterine souffle

Sound of blood going through the uterine blood vessels

What are the priority nursing measures for the infant in relation to respiration?

Suction to remove excess secretions as needed; position infant flat or on one side with the head flat or slightly elevated

List important nursing assessments after the membranes rupture. Describe normal and abnormal assessment results

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)

Describe how contractions feel to the nurse when palpated if they are mild

Uterus is easily indented like the tip of the nose

A vaginal birth after cesarean is often abbreviated __________

VBAC

What are the priority nursing measures for the infant in relation to temperature regulation?

Dry the baby quickly, including the head; place in a prewarmed radiant warmer or in skin to skin contact with a parent, which can be used to position the baby's head favorably; use a cap on the baby's dry head to reduce heat loss from that area when not in the radiant warmer

The nurse decides that Erin may be in true labor and tells her to come to the birth center. On arrival, Erin says that she thinks her "water broke." What tests might the nurse use to verify that Erin's membranes have indeed ruptured?

Either a pH or fern test or both are the two tests that are often used to evaluate whether the membranes have ruptured. Commercial tests to test for membrane rupture may be used at the birth center

The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetus is active during the initial assessment. Fetal heart rate is 135 to 150 bpm, and the rate often accelerates. Amniotic fluid is light green with small white flecks in it. Vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis. Is the amniotic fluid normal?

Except for the greenish color, the amniotic fluid is normal. The amniotic fluid is green because the fetus passed meconium before birth. Fetal problems may or may not exist

Describe characteristics of the fetal heart rate (FHR) that are reassuring when the FHR is auscultated in a term fetus

Heart rate at term with a lower limit of 110 beats per minute (bpm), upper limit of 160 bpm; regular rhythm; presence of accelerations; absence of decelerations. These signs would also be reassuring if the fetus were monitored electronically

The nurse decides that Erin may be in true labor and tells her to come to the birth center. On arrival, Erin says that she thinks her "water broke." What is the priority nursing care at this time?

Priorities are to assess the FHR and, if membranes have ruptured, the color, odor, and character of the amniotic fluid; to assess Erin's vital signs; and to determine the nearness to birth by evaluating contractions and cervical dilation.

During the labor process, the patient's membranes rupture. Select all the assessments that are necessary for the nurse to carry out at this time. (Select all that apply.) a. Color of amniotic fluid b. Odor of amniotic fluid c. Fetal heart rate d. Cervical dilation e. Cervical effacement f. Time the membranes ruptured

a. Color of amniotic fluid b. Odor of amniotic fluid c. Fetal heart rate f. Time the membranes ruptured The time of rupture of membranes, fetal heart rate, color, odor, and quantity of the amniotic fluid are noted and charted.

The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetus is active during the initial assessment. Fetal heart rate is 135 to 150 bpm, and the rate often accelerates. Amniotic fluid is light green with small white flecks in it. Vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis. How should the fetal heart rate be interpreted?

The FHR is normal for a term fetus, and it is reassuring that the FHR accelerates

After 4 hours of labor in the birth center, Erin's cervix is completely dilated and effaced, and the fetal station is 11. Erin feels the need to push during some contractions. When should Erin be positioned for birth?

The exact time to position Erin for birth will depend on how fast she has labored thus far. In general, a woman having her first baby is positioned for the birth when the fetal head crowns and remains visible between contractions

What time period does the fourth stage involve?

The first 1 to 4 hours after the placenta delivers is the fourth stage of labor

The nurse notes the following contraction pattern. Beginning of Contraction End of Contraction 11:15:00 11:15:40 11:20:00 11:20:45 11:24:00 11:24:50 11:28:30 11:29:10 11:33:00 11:33:35 Choose the correct documentation for the pattern. a. Contractions every 4 to 5 minutes, duration 35 to 50 seconds b. Contractions every 5 minutes, duration 35 to 40 seconds c. Contractions every 3 to 5 minutes, duration 30 to 50 seconds d. Contractions every 3 to 4 minutes, duration 30 to 40 seconds

a. Contractions every 4 to 5 minutes, duration 35 to 50 seconds

Labor pain management may include which one(s) of the following interventions? (Select all that apply.) a. Cool, damp washcloths on the face and neck b. Decreasing bright lights in the room c. Keeping the woman clean and dry d. Administering pain medication as ordered e. Offering simple snacks every 2 hours

a. Cool, damp washcloths on the face and neck b. Decreasing bright lights in the room c. Keeping the woman clean and dry d. Administering pain medication as ordered Providing comfort measures are important during labor. A laboring woman may have clear liquids by mouth but no solid food during active labor.

Describe basic comfort measures that the nurse can provide during labor

Use soft, indirect lighting. Keep the temperature comfortable with a fan or damp cool washcloths. Have the woman wear socks for cold feet. Keep the woman reasonably clean by changing her underpad as often as needed. Offer ice chips or wet washcloth to wet her lips. Remind her to empty her bladder at least every 2 hours. Encourage her to change positions frequently, assuming the position of comfort (except the supine position). Offer a shower, whirlpool, or other water therapy

When should the nurse not perform a vaginal examination at a woman's admission? Why?

Vaginal examination should not be routinely performed if the woman is bleeding actively, because the examination may increase bleeding; bloody show is not contraindication to vaginal examination; if fetal gestation is 36 weeks or less because of stimulation of preterm labor or preterm membrane rupture

A 39-week primigravida calls the birthing center and tells the nurse she has contractions that are 10 to 15 minutes apart and had a small gush of fluid about 1 hour ago. The nurse should tell her to a. wait until the contractions are about 5 minutes apart and come to the center. b. come to the birthing center now. c. come to the birthing center in about an hour if she lives farther than 1 hour away. d. come to the birthing center if the baby stops moving.

b. come to the birthing center now. A gush or trickle of fluid from the vagina should be evaluated as soon as possible. Waiting until the contractions are 5 minutes apart is appropriate for a primigravida if the membranes have not ruptured.

A woman's membranes rupture during a contraction. The priority nursing action is to: a. Assess the fetal heart rate. b. Note the color of the discharge. c. Check the woman's vital signs. d. Determine whether the fluid has a foul odor.

a. Assess the fetal heart rate.

Which one(s) of the following are important points when teaching a patient the proper method for pushing during the second stage of labor? (Select all that apply.) a. Begin and end by taking a deep breath and exhaling. b. Push for 4 to 6 seconds at a time. c. Take a deep breath and then push while holding her breath. d. Push at least five or six times with each contraction.

a. Begin and end by taking a deep breath and exhaling. b. Push for 4 to 6 seconds at a time. Support the woman's spontaneous pushing techniques if they are effective. The woman should push with her abdominal muscles while relaxing her perineum. If she needs coaching, teach her to begin by taking a breath and exhaling and then to take another breath and exhale while pushing for 6 seconds at a time. Sustained pushing while holding a breath (Valsalva maneuver or "purple pushing") or pushing more than four times per contraction reduces blood flow to the placenta, increases intrathoracic pressure, is fatiguing and should be discouraged.

A multigravida at 37 weeks of gestation is admitted to the labor room. She has contractions every 3 to 4 minutes lasting 40 to 50 seconds and no history of clear fluid leakage from the vagina, but complains of bright red bleeding for the past hour. The fetal heart rate is 145 beats/minute (bpm). What should be the nurse's next intervention? a. Call the physician promptly. b. Perform a vaginal exam to determine imminence of birth. c. Continue to monitor contractions and fetal heart rate. d. Administer an enema according to protocol of the agency.

a. Call the physician promptly. Bright red bleeding is a sign of complications, and the physician or primary health care provider should be notified immediately. Vaginal exams or enemas are contraindicated in the presence of bleeding. Continuing to monitor the mother and fetus is important after notifying the health care provider.

Which one(s) of the following are used to assist with the cervical ripening process prior to induction of labor? (Select all that apply.) a. Prostaglandin b. Oxytocin c. Misoprostol (Cytotec) d. Laminaria tents e. Terbutaline

a. Prostaglandin c. Misoprostol (Cytotec) d. Laminaria tents Prostaglandin E2 (PGE2) preparations may be given as an intravaginal gel, an intracervical gel, or a timed-release vaginal insert to ripen the cervix. Misoprostol can be used for both cervical ripening and induction of labor. Mechanical methods for cervical ripening are efficacious and have decreased risk of excessive uterine activity. These methods include placement of a transcervical balloon catheter, membrane stripping, or placement of hydroscopic inserts (i.e., Laminaria—sterile cone-shaped preparations of dried seaweed).

Bloody show differs from active vaginal bleeding in that bloody show: a. Quickly clots on the perineal pad. b. Is dark red and mixed with mucus. c. Flows freely during vaginal examination. d. Decreases in quantity as labor progresses.

b. Is dark red and mixed with mucus.

In caring for a low-risk woman in the active phase of labor, the nurse realizes the assessment of fetal well-being should occur a. every 15 minutes. b. every 30 minutes. c. every 5 minutes. d. every hour

b. every 30 minutes. For low-risk women, the nurse should evaluate the fetal monitoring strip or assessment fetal well-being at least every 30 minutes during the active phase of labor and every 15 minutes during the second stage. For the high-risk woman, monitoring should occur every 15 minutes during the active phase and every 5 minutes during the second stage.

When palpating labor contractions, the nurse should: a. Use the palm of one hand while palpating the lower uterus. b. Avoid palpating during the period of maximum intensity. c. Place the fingertips over the fundus of the uterus. d. Limit palpation to three consecutive contractions.

c. Place the fingertips over the fundus of the uterus.

On admission to the labor suite, a woman begins to cry out loudly, "Lord help me, I am going to die." She repeats this phrase loudly with each contraction. The nurse's best response would be to a. explain to the woman that she is disturbing other patients. b. praise her between contractions when she is quiet. c. understand that this may be a cultural mannerism and accept her individual response to labor. d. understand that this may be a cultural mannerism and do patient teaching to help her understand other ways of expressing her fear and pain.

c. understand that this may be a cultural mannerism and accept her individual response to labor. Women should be encouraged to express themselves in any way they find comforting. The cultural diversity of their expressions must be respected. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Belittling her, praising her falsely, or trying to show her a "better way" of dealing with the pain will interfere with the therapeutic relationship and lower the woman's self-esteem.

A woman having her first baby has been observed for 2 hours for labor but is having false labor contractions. Choose the most appropriate teaching before she returns home. a. "It is unlikely that your labor will be fast, so you can stay home until your water breaks." b. "If your water breaks, you can wait until contractions are 5 minutes apart or closer." c. "As long as the baby is active, there is no hurry to return to the birth center." d. "Your contractions will usually be 5 minutes apart or closer for 1 hour if labor is really happening."

d. "Your contractions will usually be 5 minutes apart or closer for 1 hour if labor is really happening."

A laboring woman who has not taken pain medication abruptly stops her previous breathing techniques during a contraction and makes low-pitched grunting sounds. The priority nursing action is to: a. Ask her whether she needs pain medication. b. Turn her to her left side. c. Assess contraction duration. d. Look at her perineum.

d. Look at her perineum.

The technique of delaying pushing until the reflex urge to push occurs may be called _____________________

delayed pushing, laboring down, rest and descend, or passive pushing

An intravenous access is started in most labor patients because of which one(s) of the following? (Select all that apply.) a. To have quick access if drugs are needed b. To provide fluids to prevent dehydration c. In case an epidural block is administered d. To provide a route for pain medications for the 48-hour postpartum period

a. To have quick access if drugs are needed b. To provide fluids to prevent dehydration c. In case an epidural block is administered An IV line provides quick access if fluids or medications are needed. Continuous fluid infusion prevents and reduces dehydration and is necessary if epidural analgesia is used. By 48 hours postpartum, mothers are expected to be on oral pain medication.

After birth, the nurse assesses the newborn. The heart rate is 90 bpm, the body is flexed, there is vigorous movement, the newborn is actively crying when stimulated, and has bluish coloration in the feet and hands. The proper Apgar score for this newborn should be a. 7. b. 8. c. 9. d. 10.

b. 8. The heart rate less than 100 bpm gets a score of 1, a lusty cry will give a score of 2 for both respiratory effort and reflex response, the flexed posture and vigorous movements give a score of 2, and the bluish coloration of the hands and feet will give a score of 1.

Which one of the following women can the nurse anticipate having difficulty dealing with labor pain? a. Primigravida who has attended childbirth preparation classes b. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. c. A woman having her sixth child and who has not attended any prenatal teaching classes d. Primigravida who has her mother as her birth support person. The mother is encouraging her with every contraction.

b. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. Previous experiences with pain can alter a woman's perception of labor pain. The woman with a prolonged labor and posterior position with the last birth will come to this labor anxious about the outcome and amount of pain. Preparation for labor and previous positive experiences will help the woman tolerate the pain. A support person who has been through the process and is encouraging can also assist the woman in a positive way.

Which one of the following measures will help prevent complications from an episiotomy? a. Pain medication every 3 to 4 hours as needed b. Cold applications after birth c. Warm applications after birth d. Early ambulation

b. Cold applications after birth Cold applications for the first 12 hours after birth may help prevent hematomas and edema. Pain medication helps treat, not prevent, the complication of pain. Early ambulation helps prevent other complications. Warm applications are contraindicated after birth; they may be used after 12 hours.

Which one of the following findings during the fourth stage would require immediate interventions by the nurse? a. Fundus firm and at midline b. Fundus firm, deviated to the right, with slight distention over the symphysis pubis c. Blood pressure and pulse slightly lower than reading during second stage of labor d. Lochia is bright red, with a few small clots

b. Fundus firm, deviated to the right, with slight distention over the symphysis pubis Even though the fundus is firm, it is not midline and the bladder is filling. A full bladder will interfere with contraction of the uterus and lead to increased bleeding. The rest of the answer choices are within normal limits for this stage.

When performing the fourth Leopold's maneuver, the nurse determines that the cephalic prominence is on the same side as the fetal back. How should this assessment be interpreted? a. The fetus is in a breech presentation, with the head extended. b. The fetus is in a face presentation, with the head extended. c. The fetus is in a transverse lie, with the face toward the mother's back. d. The fetus is in a cephalic presentation, with the head well flexed.

b. The fetus is in a face presentation, with the head extended.

A woman having her third baby has planned epidural analgesia for labor and birth. However, her labor was so rapid that she did not have the epidural. What is the best initial nursing approach in this case? a. Congratulate her on having a labor that was quicker than expected. b. Use open-ended questions to clarify her true feelings about the experience. c. Tactfully explain why a nonepidural labor and birth are actually better. d. Explain that it is often difficult to time epidural analgesia for labor

b. Use open-ended questions to clarify her true feelings about the experience.

The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's a. left upper quadrant. b. left lower quadrant. c. right upper quadrant. d. right lower quadrant.

b. left lower quadrant. The fetal heart is best heard through the fetus's upper back. Because this fetus is in a cephalic position, with the back toward the mother's left side, the Doppler should be placed in the left lower quadrant of the mother's abdomen.

Which one(s) of the following would be an indication for a cesarean birth? (Select all that apply.) a. Maternal coagulation defects b. Fetal death c. Cephalopelvic disproportion d. Active genital herpes e. Persistent nonreassuring FHR patters

c. Cephalopelvic disproportion d. Active genital herpes e. Persistent nonreassuring FHR patters Possible indications for cesarean birth include, but are not limited to, the following: dystocia; cephalopelvic disproportion; hypertension, if prompt delivery is necessary; maternal diseases such as diabetes, heart disease, or cervical cancer, if labor is not advisable; active genital herpes; some previous uterine surgical procedures such as a classic cesarean incision or removal of fibroid tumors; persistent indeterminate or abnormal FHR patterns; prolapsed umbilical cord; fetal malpresentations such as breech or transverse lie; hemorrhagic conditions such as abruptio placentae or placenta previa; and maternal request.

A patient is being discharged, having been diagnosed with false labor. The nursing diagnosis for her is Deficient Knowledge: characteristics of true labor. An appropriate expected outcome for this diagnosis is that the a. Patient will return to the hospital when she is in true labor. b. Patient will define true labor. c. Patient will describe reasons for returning to the hospital for evaluation. d. Patient will be able to determine false from true labor.

c. Patient will describe reasons for returning to the hospital for evaluation. The patient may not be able to determine true from false labor; however, she should be made aware of what signs to look for that may indicate the need for evaluation.

A pregnant patient walks into the birthing center complaining of contractions. After getting her to bed, the first thing the nurse should do is a. assess the mother's pulse and respirations. b. gather information about her medical history. c. assess the fetal heart rate. d. start an intravenous line.

c. assess the fetal heart rate. Assessment priorities on admission of a labor patient are to determine the condition of the mother and fetus and whether birth is imminent. Checking the fetal heart rate is one of the first assessments that should be carried out. Along with assessing the fetus, the nurse should also check the maternal blood pressure and temperature.

A primigravida is admitted in early labor. The nurse notices on the prenatal record that the position of the fetus is left occiput posterior. Because of this information, the nurse can anticipate a. a cesarean section. b. a short labor and birth process. c. increased back pain with labor. d. a short labor with a prolonged birth process.

c. increased back pain with labor. When the fetus is in the posterior position, the labor may be longer and more uncomfortable. Back discomfort increases with contractions and will continue between contractions. The fetus may not be able to deliver until it rotates into the anterior position.

Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse's action should be to a. administer the medication vaginally. b. administer the medication orally. c. question the dosage amount. d. monitor for contractions before administering the medication.

c. question the dosage amount. The normal dose of misoprostol for cervical ripening is 25 mcg. A 50-mcg dose is associated with hypertonic contractions.

When performing Leopold's maneuvers, the nurse palpates a hard round object in the uterine fundus. A smooth rounded surface is on the mother's right side, and irregular movable parts are felt on her left side. An irregularly shaped fetal part is felt in the suprapubic area and is easily moved upward. How should these findings be interpreted? a. The fetal presentation is cephalic, position is ROA, and the presenting part is engaged. b. The fetal presentation is cephalic, position is LOP, and the presenting part is not engaged. c. The fetal presentation is breech, position is RST, and the presenting part is engaged. d. The fetal presentation is breech, position is RSA, and the presenting part is not engaged.

d. The fetal presentation is breech, position is RSA, and the presenting part is not engaged.

When auscultating the fetal heart rate of a term fetus during labor, the nurse notes a rate of 130 to 140 beats per minute (bpm), with occasional accelerations in the rate. How should the nurse interpret the data? a. The baseline rate is slightly high for a term fetus. b. Accelerations in the rate suggest intermittent hypoxia. c. Labor usually causes the fetal heart rate to be slower. d. These assessments are normal for a term fetus during labor.

d. These assessments are normal for a term fetus during labor.

List three characteristics of tetanic (hypertonic) contractions. Why is it important to watch for this type of contraction?

durations longer than 90 to 120 seconds; intervals shorter than 30 seconds; incomplete uterine relaxation between contractions. If tetanic or hypertonic, contractions are too long or too frequent, or if too little uterine relaxation exists, fetal oxygenation may be reduced