OB Ch 14 Nursing Management During L&D

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 student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant.

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

respiratory rate

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.

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?

Placing a wedge under the hips

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

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

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 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?

These methods are a technique to prevent the painful stimuli from entering the brain.

The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?

Thoroughly wash the hands before and after client contact.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

determining fetal position, presentation, and lie

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

dilation of the cervix

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

effleurage

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

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

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

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

instruct the client or her partner to perform light fingertip repetitive abdominal massage.

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

maternal hypotension and fetal bradycardia

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 seconds

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?

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

The nurse in an obstetric clinic is conducting client education with a group of expectant mothers. One young woman asks the nurse to tell the group what labor pain is like. What would be the nurse's best response?

"The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in."

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

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate.

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

Assess vital signs.

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 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.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing

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.

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs.

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

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

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 by Doppler at which frequency?

every 15 min

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?

every 15 minutes

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?

every 30 min

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

fear of pain during labor

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply.

fetal bradycardia recurrent late decelerations sinusoidal pattern