OB Exam 2: Intrapartum

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

What is the most likely cause for a variable deceleration? A. Administration of an epidural for pain relief during labor B. Cord compression C. Breech position of fetus D. Administration of meperidine (Demerol) for pain relief during labor

B. Cord compression Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern.

Which patient will most likely have increased anxiety and tension during labor? A. Gravida 2 who refused any medication B. Gravida 2 who delivered a stillborn baby last year C. Gravida 1 who did not attend prepared childbirth classes D. Gravida 3 who has two children younger than 3 years

B. Gravida 2 who delivered a stillborn baby last year If a previous pregnancy had a poor outcome, the patient will probably be more anxious during labor and birth. The patient without childbirth education classes is not prepared for labor and will have increased anxiety during labor; however, the patient with a poor previous outcome is more likely to experience a greater degree of anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect.

During each contraction, the nurse notices that the woman stops talking and stares at a picture on the wall. The nurse realizes that the woman is using the picture as a A. point of imagery. B. focal point. D. distraction.

B. focal point.

The nurse notices on the admission record that the fetus is in a cephalic military presentation. The nurse realizes that the fetus A. is coming feet first into the birth canal. B. has the head in the birth canal first, but the head is not flexed. C. has the head in the birth canal first, and the head is in a flexed presentation. D. has both feet coming into the birth canal first.

B. has the head in the birth canal first, but the head is not flexed.

When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated? A. Lower the head of the bed. B. Place a wedge under the left hip. C. Change her position to the right side. D. Place the mother in Trendelenburg position.

C. Change her position to the right side. A Category II pattern indicates an indeterminate fetal heart rate. Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice.

The process of labor places significant metabolic demands on the obstetric patient. Which physiologic findings would be expected? A. Decreased maternal blood pressure as a result of stimulation of alpha receptors B. Uterine vasoconstriction as a result of stimulation of beta receptors C. Increased maternal demand for oxygen D. Increased blood flow to placenta because of catecholamine release

C. Increased maternal demand for oxygen With regard to labor, one would expect to see an increase in maternal blood pressure because of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The maternal metabolic rate is increased during labor, along with an increase in maternal demand for oxygen.

The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers? A. To determine the status of the membranes B. To determine cervical dilation and effacement C. To determine the best location to assess the fetal heart rate D. To determine whether the fetus is in the posterior position

C. To determine the best location to assess the fetal heart rate Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A pH test or fern test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

A woman is receiving oxytocin for labor induction. The nurse notices the woman is having contractions every 2 minutes lasting for 100 seconds. The fetal heart rate is 120 to 130 bpm, with moderate variability. The nurse's next action should be to: A. Continue to monitor. B. Notify the physician. C. Turn off the oxytocin. D. Turn the oxytocin up to a stronger level.

C. Turn off the oxytocin.

If a notation on the patient's health record states that the fetal position is LSP, this indicates that the A. head is in the right posterior quadrant of the pelvis. B. head is in the left anterior quadrant of the pelvis. C. buttocks are in the left posterior quadrant of the pelvis. D. buttocks are in the right upper quadrant of the abdomen.

C. buttocks are in the left posterior quadrant of the pelvis. LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.

A woman is admitted in early labor. The prenatal record states that the fetus is in a transverse lie with a shoulder presentation. The nurse can anticipate a A. frequent change of positions for the mother to alter the fetal position. B. need for early fetal monitoring to assess for fetal heart changes. C. cesarean birth. D. prolonged second stage of labor.

C. cesarean birth.

A patient in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with A. visceral pain. B. tissue ischemia. C. somatic pain. D. cervical dilation.

C. somatic pain. This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus. The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the patient is already fully dilated so this would not be a factor.

A gravida 1 woman who is 39 weeks of gestation and has had no prenatal care is admitted into the labor unit in early labor. During the assessment, the nurse finds the fetal heart tones in the right upper quadrant. The nurse should anticipate A. a precipitous labor. B. a prolonged first stage of labor. C. a cesarean birth. B. rupture of membranes.

C. a cesarean birth.

The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing A. a worsening hypoxia. B. progressive acidosis. C. an expected response. D. parasympathetic stimulation.

C. an expected response. The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) baseline. An increase in the FHR with stimulation does not indicate hypoxia. An increase in the FHR after stimulation is an anticipated response and does not indicate acidosis. An increase in the FHR after stimulation is a normal pattern, and does not indicate problems with the parasympathetic nervous system. A Category I pattern is normal and strongly predictive of adequate fetal acid-base status.

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.

A woman who has been admitted for preterm labor is started on terbutaline (Brethine) to decrease uterine irritability. Within 24 hours the contractions have stopped and the woman is resting comfortably. During vital sign assessment the nurse records a blood pressure reading of 125/74, pulse 95, respirations 12. The blood pressure and respirations are within limits of previous readings, but the pulse has increased from a previous reading of 76 to 80. The nurse's next action should be to: A. assess for internal bleeding. B. continue to monitor the pulse rate at regular intervals. C. assess the fetal heart rate. D. reassess the vital signs in 1 hour.

C. assess the fetal heart rate.

Which one of the following findings meets the criteria of a Category I FHR pattern? A. The FHR does not change as a result of fetal activity. B. The average baseline rate ranges between 90 and 110 bpm. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 and 25 bpm.

D. Variability averages between 6 and 25 bpm.

The pregnant patient expresses a desire to schedule birth during the baby's father's furlough from military service. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding? a. Dilated cervix b. Fetal lung maturity c. Rupture of membranes d. Uterine hypertonia

b. Fetal lung maturity Reassurance of fetal lung maturity is essential before elective procedures such as induction or cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction. Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor associated with induction of labor.

Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Station b. Flexion c. Descent d. Engagement

b. Flexion The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid

b. Gynecoid The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes.

The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension b. Fetal heart rate of 140 to 150 bpm c. Meconium-stained amniotic fluid d. Maternal fever—38C (100.4F) or higher e. Complete uterine relaxation of more than 30 seconds between contractions

a. Maternal hypotension c. Meconium-stained amniotic fluid d. Maternal fever—38C (100.4F) or higher Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38C [100.4F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

To ensure adequate fetal oxygenation, which one(s) of the following are needed? (Select all that apply.) a. Normal maternal blood flow and volume to the placenta b. Normal oxygen saturation in maternal blood c. Normal carbon dioxide saturation in the maternal blood d. Adequate exchange of oxygen and carbon dioxide in the placenta e. Normal fetal circulatory and oxygen-carrying functions f. Normal blood glucose levels in the fetal circulation

a. Normal maternal blood flow and volume to the placenta b. Normal oxygen saturation in maternal blood d. Adequate exchange of oxygen and carbon dioxide in the placenta e. Normal fetal circulatory and oxygen-carrying functions

Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.

a. cesarean birth. Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.

A woman who is 27 weeks pregnant calls the clinic and complains of constant low backache. The nurse should: a. have the woman come in to be evaluated. b. have the woman call back in 1 day if the backache does not improve. c. have the woman call back if the pain increases. d. tell the woman to drink plenty of fluids and maintain bed rest.

a. have the woman come in to be evaluated.

During active labor, the woman complains about tingling in her hands. The nurse's next action should be to a. help the woman slow down her breathing and breathe into her cupped hands. b. assess vital signs for changes. c. check cervical dilation. d. change the woman's position.

a. help the woman slow down her breathing and breathe into her cupped hands.

A laboring patient who imagines her body opening to let the baby out is using a mental technique called a. imagery. b. effleurage. c. distraction. d. dissociation.

a. imagery. Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working.

During labor a vaginal examination should be performed only when necessary because of the risk of a. infection. b. fetal injury. c. discomfort. d. perineal trauma.

a. infection. Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should a. maintain the normal assessment routine. b. administer O2 at 8 to 10 L/minute by face mask. c. increase the IV flow rate from 125 to 150 mL/hour. d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

a. maintain the normal assessment routine. Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary within early decelerations.

If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position.

a. massage the fundus. The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. palpate the infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.

a. palpate the infant's clavicles.

The nurse thoroughly dries the infant immediately after birth primarily to a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface.

a. reduce heat loss from evaporation. Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

When reviewing the prenatal record of a patient at 42 weeks' gestation, the nurse recognizes that induction of labor is based upon which indication? a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-lb weight gain at each of the last two weekly visits.

a. reduced amniotic fluid volume. Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-lb weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation.

A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time d. Faster descent of the fetus e. An increase in frequency of contractions

a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body's signals. A brief slowing of contractions often occurs at the beginning of the second stage.

Which patient will be most receptive to teaching about nonpharmacologic pain control methods? A. Gravida 1, para 0, in transition B. Gravida 2, para 1, admitted at 8 cm c. Gravida 1, para 0, dilated 2 cm, 80% effaced d. Gravida 3, para 2, complaining of intense perineal pressure

c. Gravida 1, para 0, dilated 2 cm, 80% effaced The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Patients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a patient whose birth is imminent.

The nurse is reviewing the cardinal maneuvers of labor and birth with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head? a. Expulsion b. Restitution c. Internal rotation d. External rotation

b. Restitution After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

The fetus in a breech presentation is often born by cesarean birth because a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the patient delivers vaginally.

b. compression of the umbilical cord is more likely. After the fetal legs and trunk emerge from the patient's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.

A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours on March 12. The nurse knows that the next dose must be scheduled for a. 1430 hours on March 12th. b. 2030 hours on March 12th. c. 0830 hours on March 13th. d. 1430 hours on March 13th.

c. 0830 hours on March 13th. The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 1430 hours on March 12th, 2030 hours on March 12th, and 1430 hours on March 13th do not fall within this recommendation. The next dose should be scheduled for 0830 hours on March 13th.

Which breech presentation should the nurse recognize as being favorable for an external cephalic version? a. 36-week gestation with low-lying placenta b. 38-week gestation with one previous cesarean c. 37-week gestation with fetal weight of 7 lb d. 40-week gestation with several uterine fibroids

c. 37-week gestation with fetal weight of 7 lb An external cephalic version (changing the fetal presentation from breech to cephalic) is more successful when the pregnancy is at least 37 weeks and there is still adequate room and fluid to manipulate the fetus but prior to term or onset of labor. A low-lying placenta, previous cesarean birth, and uterine fibroids are contraindications for version.

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink and the hands and feet are blue. The Apgar score for this infant is a. 7. b. 8. c. 9. d. 10.

c. 9. The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.

Which clinical finding would be considered normal for a preterm fetus during the labor period? A. Baseline tachycardia B. Baseline bradycardia C. Fetal anemia D. Acidosis

A. Baseline tachycardia Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

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.

Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, ?2-1. Which one of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. Fetus has passed through the ischial spines.

A. Fetal presenting part is 1 cm above the ischial spines.

Which one(s) of these conditions might cause late decelerations in the fetal heart rate? (Select all that apply.) A. Maternal hypotension B. Excessive uterine activity C. Maternal hypertension D. Fever E. Maternal overhydration F. Prolapsed cord

A. Maternal hypotension B. Excessive uterine activity C. Maternal hypertension

Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) A. Oxytocin (Pitocin) B. Misoprostol (Cytotec) C. Dinoprostone (Cervidil) D. Methylergonovine maleate (Methergine)

A. Oxytocin (Pitocin) B. Misoprostol (Cytotec) C. Dinoprostone (Cervidil) D. Methylergonovine maleate (Methergine) Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants. Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid.

Immediately following an amniotomy to observe for complications, the nurse must assess the A. fetal heart rate. B. maternal blood pressure. C. maternal pulse. D. fetal heart rate variability.

A. fetal heart rate.

The nurse should tell a primigravida that the definitive sign indicating labor has begun is A. progressive uterine contractions. B. lightening. C. rupture of membranes. D. passage of the mucus plug.

A. progressive uterine contractions.

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.

Firm sacral pressure is likely to be most helpful in which situation? A. Rapid labor and birth B. Fetal occiput posterior position C. Oxytocin induction of labor D. If analgesics should be avoided

B. Fetal occiput posterior position

Which assessment finding indicates that cervical dilation and/or effacement has occurred? A. Onset of irregular contractions B. Cephalic presentation at 0 station C. Bloody mucus drainage from vagina D. Fetal heart tones (FHTs) present in the lower right quadrant

C. Bloody mucus drainage from vagina Cervical dilation and/or effacement results in loss of the mucus plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

Which type of uterine rupture may go undiagnosed during labor and the postpartum period? A. Complete rupture B. Incomplete rupture C. Dehiscence D. All of the ruptures are detectable by electronic uterine monitoring.

C. Dehiscence

When doing a vaginal exam, the nurse notes a triangular-shaped depression toward the mother's left side and pointing up toward her abdomen. The nurse can record the fetal position as A. LOP. B. ROP. C. LOA. D. ROP.

C. LOA.

Which assessment finding would cause a concern for a patient who had delivered vaginally? A. Estimated blood loss (EBL) of 500 mL during the birth process B. White blood cell count of 28,000 mm3 postbirth C. Patient complains of fingers tingling D. Patient complains of thirst

C. Patient complains of fingers tingling A patient's complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the patient slow breathing down and restore normal carbon dioxide levels.

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.

A woman must have general anesthesia for a planned cesarean birth because of a previous back surgery. The nurse should therefore expect to administer A. naltrexone (Trexan). B. an oral barbiturate. C. ranitidine (Zantac). D. promethazine (Phenergan).

C. ranitidine (Zantac).

A woman admitted with preterm labor is started on nifedipine (Procardia) to reduce uterine muscle contractions. The nurse should include in this woman's care plan a nursing diagnosis of: A. risk for deficient fluid volume. B. risk for infection. C. risk for injury. D. activity intolerance.

C. risk for injury.

During labor, the nurse notices that the woman's support partner touches her lightly during contractions. When the woman is touched, she relaxes her muscles. The nurse realizes that the couple is using the technique of A. progressive relaxation. B. neuromuscular disassociation. C. touch relaxation. D. relaxation against pain.

C. touch relaxation.

Why is continuous electronic fetal monitoring generally used when oxytocin is administered? A. Fetal chemoreceptors are stimulated. B. The mother may become hypotensive. C. Maternal fluid volume deficit may occur. D. Uteroplacental exchange may be compromised.

D. Uteroplacental exchange may be compromised. The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk.

To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should A. give the woman oxygen. B. turn the woman to the right side. C. decrease the intravenous infusion rate. D. place a wedge under the woman's right hip.

D. place a wedge under the woman's right hip. Tilting the woman's pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. Placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.

The laboring patient asks the nurse how the labor contractions cause the cervix to dilate. The nurse responds that labor contractions facilitate cervical dilation by A. promoting blood flow to the cervix. B. contracting the lower uterine segment. C. enlarging the internal size of the uterus. D. pulling the cervix over the fetus and amniotic sac.

D. pulling the cervix over the fetus and amniotic sac. Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

Uncontrolled maternal hyperventilation during labor results in A. metabolic acidosis. B. metabolic alkalosis. C. respiratory acidosis. D. respiratory alkalosis.

D. respiratory alkalosis. Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

Which intervention is an essential part of nursing care for a laboring patient? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety

a. Helping the woman manage the pain Helping a patient manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important; however, managing pain is a top priority.

On vaginal exam, the patient's cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishop's score for this patient is a. 6. b. 9. c. 10. d. 12.

b. 9. On the Bishop's scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70% effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9.

A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test? a. Patient must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Patient should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.

c. Patient should refrain from sexual activity prior to testing. Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

The midwife records that the patient's cervix is "100%, 5 cm." The nurse understands that the patient's cervix is a. completely dilated and effaced b. completely dilated and half effaced c. completely effaced and half dilated d. half dilated and half effaced

c. completely effaced and half dilated

Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.

d. Contractions abruptly stop during labor. A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

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

The laboring woman may rub her abdomen during a contraction to counteract discomfort. This is called ______________________.

effleurage

Which maternal factor may inhibit fetal descent during labor? A. A full bladder B. Decreased peristalsis C. Rupture of membranes D. Reduction in internal uterine size

A. A full bladder A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

Which patient is most at risk for a uterine rupture? A. A gravida 4 who had a classic cesarean incision B. A gravida 5 who had two vaginal births and one cesarean birth c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

A. A gravida 4 who had a classic cesarean incision The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The patient who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low-segment incisions do not raise the risk of uterine ruptures.

Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) A. A gush of blood appears. B. The uterus rises upward in the abdomen. C. The fundus descends below the umbilicus. D. The cord descends further from the vagina. E. The uterus becomes boggy and soft, with an elongated shape.

A. A gush of blood appears. B. The uterus rises upward in the abdomen. D. The cord descends further from the vagina. Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected.

Which of the following is the priority intervention for the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? A. Administer O2 at 8 to 10 L/minute. B. Decrease the IV rate to 100 mL/hour. C. Reposition the ultrasound transducer. D. Perform a vaginal exam to assess for cord prolapse.

A. Administer O2 at 8 to 10 L/minute. A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the patient's blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation.

A patient is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or perform procedures? A. After the contraction is over B. When it is all right with the coach C. During the increment of the next contraction D. After administration of analgesic-anesthetic

A. After the contraction is over Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly.

Which one(s) of the following are considered abnormal (Category III) heart rate patterns? (Select all that apply.) A. Bradycardia B. Absent variability C. Early decelerations D. Recurrent variable decelerations

A. Bradycardia B. Absent variability D. Recurrent variable decelerations

Which one(s) of the following actions should be included in nursing care during labor? (Select all that apply.) A. Offer ice chips in small amounts to relieve a dry mouth. B. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. C. Keep the woman in a side-lying position to prevent supine hypotension. D. Offer small bland meals if the woman is in early labor to help maintain proper blood sugar levels. E. Monitor the fetal heart rate for changes from normal.

A. Offer ice chips in small amounts to relieve a dry mouth. B. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. C. Keep the woman in a side-lying position to prevent supine hypotension. E. Monitor the fetal heart rate for changes from normal.

The primary difference between the labor of a nullipara and that of a multipara is A. total duration of labor. B. level of pain experienced. C. amount of cervical dilation. D. sequence of labor mechanisms.

A. total duration of labor. Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

Which one of the following characteristics is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency is established D. Progressive in terms of intensity and duration

B. Decrease in intensity with ambulation

As the nurse is admitting a woman in labor, she notices that the woman is happy and excited that she is in labor. The contractions are 5 minutes apart, lasting 30 to 35 seconds. The nurse can anticipate that the patient is in which phase of labor? A. Second B. Latent C. Active D. Transition

B. Latent

The midwife has just examined a labor patient and states that she is 10 cm dilated. The nurse is aware that this patient is in which stage of labor? A. First B. Second C. Third D. Fourth

B. Second

On 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.

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

The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction? A. Little to no affect B. Increases as blood pressure decreases C. Diminishes as the spiral arteries are compressed D. Continues except when placental functions are reduced

C. Diminishes as the spiral arteries are compressed During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

The postpartum woman who had a long labor induced by oxytocin is at higher risk for which complication? A. Thrombophlebitis B. Hemorrhage C. Lacerations of the vaginal area D. Altered urinary elimination

C. Lacerations of the vaginal area

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? A. Reposition the patient. B. Apply a fetal scalp electrode. C. Record this normal pattern. D. Administer oxygen by nasal cannula.

C. Record this normal pattern.

After birth, the woman complains of chills. The first intervention by the nurse should be to A. monitor the maternal temperature. B. monitor the maternal blood pressure. C. place a warm blanket on the woman. D. explain to the woman this is caused by the excitement of birth and will stop in about 30 minutes.

C. place a warm blanket on the woman.

To relieve a mild postdural puncture headache, the nurse should encourage the intake of A. milk. B. orange juice. C. tea or coffee. D. beef or chicken bouillon.

C. tea or coffee. Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine. Some patients prefer a cold caffeinated soft drink over coffee or tea.

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.

Research has found that bed rest as an intervention for preventing preterm labor can result in A. maternal weight gain. B. diarrhea. C. increased maternal plasma volume and cardiac output. D. bone demineralization with calcium loss.

D. bone demineralization with calcium loss.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be A. severe postpartum headache. B. limited perception of bladder fullness. C. increase in respiratory rate. D. hypotension.

D. hypotension.

Variability can be reduced by which one(s) of the following factors? (Select all that apply.) a. Sleep b. Narcotics c. Gestation longer than 39 weeks d. Fetal anomalies that affect the central nervous system

a. Sleep b. Narcotics d. Fetal anomalies that affect the central nervous system

While caring for a woman who is 10 cm dilated and is pushing, the nurse notices that the fetal heart rate has dropped to 85 bpm. The station is +3. The nurse can anticipate: A. A cesarean section. B. A low operative vaginal birth. C. A midpelvis operative vaginal birth. D. No change in the birth plan.

.B. A low operative vaginal birth

An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of A. lightening. B. breech presentation. C. urinary tract infection. D. onset of Braxton-Hicks contractions.

A. lightening. As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

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.

A woman has reached 10 cm and is attempting to push. She had an epidural and is unable to feel the urge to push. The nurse can best assist her by a A. allowing the epidural to wear off and then have her push. B. letting her labor down, that is delaying pushing until she feels the reflexive urge to push. C. changing her position to a side-lying. E. preparing her for a forceps birth.

B. letting her labor down, that is delaying pushing until she feels the reflexive urge to push.

During birth, shoulder dystocia was diagnosed. After the birth and the newborn has been stabilized, it is important for the nurse to assess the newborn for A. hip dysplasia. B. lung excursion. C. fractured clavicles. D. clubfoot.

C. fractured clavicles.

On review of a fetal monitor tracing, the nurse notes that for several contractions the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should A. describe the finding in the notes. B. reposition the woman onto her side. C. call the physician for instructions. D, administer oxygen at 8 to10 L/minute with a tight face mask.

B. reposition the woman onto her side.

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position and her vital signs are stable and within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to A. change the woman's position. B. stop the oxytocin. C. elevate the woman's legs. D. administer oxygen via a tight mask at 8 to 10 L/minute.

B. stop the oxytocin.

A woman came for a prenatal check up on March 15. She tells the nurse her last normal menstrual period was June 2. The nurse is aware that she will be scheduled for: A. immediate delivery. B. test to determine fetal well-being. C. follow-up appointments every week until delivery. D. ultrasound to determine fetal age.

B. test to determine fetal well-being.

During the latent phase of labor, the nurse suggests that the woman play cards with her husband. The nurse is aware that this will help the woman deal with the pain of contractions. The effectiveness of this technique is explained by: A. cutaneous stimulation B. the gate control theory C. thermal stimulation D. hydrotherapy

B. the gate control theory

The primary side effect of maternal narcotic analgesia in the newborn is A. tachypnea. B. bradycardia. C. acrocyanosis. D. respiratory depression.

D. respiratory depression. An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics.

The term that describes a labor lasting 3 hours or less is ____________.

Precipitate labor

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

If the head retracts against the perineum after the birth, it is commonly referred to as the __________________.

Turtle sign

A vaginal birth after cesarean is often abbreviated _________

VBAC

As full term nears, the cervix softens because of the effects of the hormone relaxin and increased water content. This cervical change is termed __________.

ripening

Fluctuations in the baseline FHR that cause the printed line to have an irregular rather than a smooth appearance is termed ___________________.

variability

A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet; however, it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. Which questions should the nurse pose to the patient during this telephone triage? (Select all that apply.) A. Does she think that her membranes have ruptured? B. Is there any evidence of bloody show? C. Instruct the patient to keep monitoring her contraction pattern and call you back if they become more regular. D. When is her next scheduled visit with her health care provider? E. Tell her to come into the hospital for evaluation.

A. Does she think that her membranes have ruptured? E. Tell her to come into the hospital for evaluation. The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus in view of the assessment data that the patient provided, the nurse should ascertain membrane status and ask the patient to come in for evaluation. The patient has already indicated that the vaginal discharge was not bloody in nature. Having the patient continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the patient about the next scheduled physician visit does not address current health concerns of impending labor.

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

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

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include which of the following? (Select all that apply.) A. Culture B. Anxiety and fear C. Support systems D. Preparation for childbirth E. Previous experiences with pain

A. Culture B. Anxiety and fear C. Support systems D. Preparation for childbirth E. Previous experiences with pain Culture: A woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and birth. Preparation for childbirth: This does not ensure a pain-free labor. Preparation does reduce anxiety and fear. It also allows a woman to rehearse for labor. Previous experiences with pain: Fear and withdrawal are natural responses to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage? A. Latent phase B. Active phase C. Second stage D. Transition phase

A. Latent phase The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

A woman is receiving magnesium sulfate intravenously to control preterm labor. She is at the maximum dose and the contractions have slowed to eight per hour. The nurse is assessing the woman's vital signs every hour. Besides the blood pressure, pulse, and respirations, what other assessments should be carried out hourly? A. Lung sounds B. Edema in lower extremities C. Bowel sounds D. Range of motion to the lower extremities

A. Lung sounds

A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated with opiate-dependent patients? A. Nalbuphine (Nubain) B. Hydroxyzine (Vistaril) C. Promethazine (Phenergan) D. Diphenhydramine (Benadryl)

A. Nalbuphine (Nubain) Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics.

Which patient is a candidate for internal monitoring with an intrauterine pressure catheter? A. Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds B. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds C. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds D. Gravida 2, para 1, in latent phase whose contractions are irregular and mild

A. Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase.

In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? A. The fetus is at 30 weeks of gestation. B. The mother has a history of fast labors. C. The mother has been given an epidural block. D. The mother has mild preeclampsia but is not in labor.

A. The fetus is at 30 weeks of gestation. The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR.

A patient just delivered her baby via the vaginal route. The patient asks the nurse why the baby's head is not round, but oval. Which explanation should the nurse provide the patient? A. This results from molding. B. This results from lightening. C. This results from the fetal lie. D. This results from the fetal presentation.

A. This results from molding. The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

Which physical factors contribute to pain during labor and birth? (Select all that apply.) A. Tissue ischemia B. Cutting of the nerves with dilation C. Cervical dilation D. Distention of the vagina and perineum E. Height of the woman in relation to fetal size.

A. Tissue ischemia C. Cervical dilation D. Distention of the vagina and perineum

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

Which maternal condition should be considered a contraindication for the application of internal monitoring devices? A. Unruptured membranes B. Cervix dilated to 4 cm C. Fetus has known heart defect D. Maternal HIV

A. Unruptured membranes To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. An internal electrode should not be placed if the patient has hemophilia, maternal HIV, or genital herpes.

A woman with an epidural has been pushing for the past 2 hours with very little progression. An appropriate nursing action at this point is to A. assess for a full bladder. B. assess for a full colon. C. allow the woman to rest for two or three contractions before starting to push again. D. change positions of the woman and attempt to push again.

A. assess for a full bladder.

Which of the following women will have the most successful induction of labor? A. Primigravida, Bishop score of 9, fFN is positive B. Gravida 2, Bishop score of 6, fFN is positive C. Gravida 2, Bishop score of 8, fFN is negative D. Primigravida, Bishop score of 5, fFN is negative

A. Primigravida, Bishop score of 9, fFN is positive

During a vaginal exam, the physician stimulates the fetal scalp. The fetal heart rate accelerated from 140 to 155 bpm for about 30 seconds. The nurse should A. record this fetal reaction. B. notify the physician because this reaction is normal. C. assist the woman into a side-lying position. D. administer oxygen at 8 to 10 L/minute.

A. record this fetal reaction.

A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor? A. Latent phase B. Active phase C. Second stage D. Third stage

B. Active phase The active phase of labor is characterized by cervical dilation of 5 to 6 cm. Historically, the latent phase is from the beginning of true labor until 3 cm of cervical dilation. Recent research has suggested that the latent phase be considered to last up until 5 to 6 cm. dilated. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

A laboring woman just had an amniotomy performed to augment labor. The nurse is aware that the assessment times for which vital signs will be altered? A. Maternal blood pressure B. Maternal pulse C. Maternal temperature D. Maternal respiration

C. Maternal temperature

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe which one of the following? A. Weight gain of 1 to 3 lb B. Quickening C. Fatigue and lethargy D. Bloody show

D. Bloody show

A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with A. more rapid labor. B. a high risk of infection. C. maternal perineal trauma. D. umbilical cord compression.

D. umbilical cord compression. The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth. Most breech presentations are now delivered by caesarean birth.

A patient who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "You should come into the office and let the doctor check you." b. "Acetaminophen is acceptable during pregnancy. You should not take aspirin, however." c. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."

a. "You should come into the office and let the doctor check you." A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The patient needs to be assessed for preterm labor before providing pain relief.

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge b. 20-gauge c. 22-gauge d. 24-gauge

a. 18-gauge The nurse should select the largest bore cannula possible. An 18-gauge cannula is the largest size available. A 24-gauge cannula would be the smallest. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

For which patient should the oxytocin (Pitocin) infusion be discontinued immediately? a. A patient in transition with contractions every 2 minutes lasting 90 seconds each b. A patient in early labor with contractions every 5 minutes lasting 40 seconds each c. A patient in active labor with contractions every 3 minutes lasting 60 seconds each d. A patient in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each

a. A patient in transition with contractions every 2 minutes lasting 90 seconds each This patient's contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this patient's contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this patient's contractions. There is an appropriate resting period between this patient's contractions for her stage of labor.

To obtain an accurate blood pressure of a woman in labor, the nurse should assess the blood pressure a. between contractions, with the woman lying on her side b. between contractions with the woman lying on her back c. with a contraction while the woman is lying on her sided. d. with a contraction while the woman is lying on her back

a. between contractions with the woman lying on her side

Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of -3 d. Meconium-stained amniotic fluid

c. Presenting part at a station of -3 Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the patient at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.

How does childbirth pain differs from other types of pain? (Select all that apply.) A. It is a normal process. B. There is preparation time. C. It is stronger than most other types of pain. D. It is self-limiting. E. It is intermittent. F. It is always a dull, achy type of pain.

A. It is a normal process. B. there is preparation time D. It is self-limiting. E. It is intermittent.

The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's most respectful approach for this patient? A. Ask the patient's labor coach if this is a usual expression of pain for her. B. Refer to the patient's chart to determine any orders for pain medication. C. Tell the patient that she is disturbing the other laboring patients on the unit. D. Encourage the patient to try to suppress her noisiness during contractions.

A. Ask the patient's labor coach if this is a usual expression of pain for her. Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a woman's personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others.

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.

Which one(s) of the following are considered theories about the onset of labor? (Select all that apply.) A. Changes in the relative effects of estrogen and progesterone B. An increase in prostaglandins C. Increased secretion of prolactin D. Decreased secretion of oxytocin E. Stretching and irritation of the uterus and cervix

A. Changes in the relative effects of estrogen and progesterone B. An increase in prostaglandins E. Stretching and irritation of the uterus and cervix

A laboring patient asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? A. The acme B. The interval C. The increment D. The decrement

A. The acme The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes. Which supplies should the nurse gather? (Select all that apply.) A. Extra underpads B. Solution of 3% normal saline C. Amniotic hook to perform an amniotomy D. Solid intrauterine pressure catheter with a pressure transducer on its tip

A. Extra underpads C. Amniotic hook to perform an amniotomy Amnioinfusion is performed with lactated Ringer's solution or normal saline, not 3%. Normal saline is infused into the uterus through an intrauterine pressure catheter (IUPC). The underpads must be changed regularly because fluid leaks out constantly. The membranes need to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed. The IUPC must have a double lumen to run the infusion through.

Why is a cleansing breath at the beginning and end of contractions important? (Select all that apply.) A. Helps the woman release tension B. Provides oxygen to reduce myometrial hypoxia C. Provides a diversional activity for the woman D. Helps the fetus to release tension

A. Helps the woman release tension B. Provides oxygen to reduce myometrial hypoxia

A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.) A. In true labor, the cervix begins to dilate. B. In true labor, the contractions are felt in the abdomen and groin. C. In true labor, contractions often resemble menstrual cramps during early labor. D. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. E. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

A. In true labor, the cervix begins to dilate. C. In true labor, contractions often resemble menstrual cramps during early labor. E. In true labor your contractions tend to increase in frequency, duration, and intensity with walking. In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity.

The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) A. Offer the patient a warm blanket. B. Place an ice pack on the perineum. C. Massage the uterus if it is boggy. D. Delay breastfeeding until the patient is rested. E. Explain to the patient that the lochia will be light pink in color.

A. Offer the patient a warm blanket. B. Place an ice pack on the perineum. C. Massage the uterus if it is boggy. The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the most appropriate nursing action at this time? A. Place a warm blanket over the patient. B. Place the baby on the patient's abdomen. C. Tell the patient that chills are expected after birth. D. "What do you mean by your words 'very cold'?"

A. Place a warm blanket over the patient. Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

Relaxation of the mother during labor is important for several reasons. Which one(s) of the following are reasons that promoting relaxation is important? (Select all that apply.) A. Promotes uterine blood flow B. Improves fetal oxygenation C. Promotes efficient uterine contractions D. Reduces tension that increases pain E. Inhibits rapid fetal descent

A. Promotes uterine blood flow B. Improves fetal oxygenation C. Promotes efficient uterine contractions D. Reduces tension that increases pain

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

Which comfort measure should the nurse utilize in order to enable a laboring woman to relax? A. Recommend frequent position changes. B. Palpate her filling bladder every 15 minutes. C. Offer warm wet cloths to use on the patient's face and neck. D. Keep the room lights lit so the patient and her coach can see everything.

A. Recommend frequent position changes. Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief. Soft indirect lighting is more soothing than irritating bright lights.

Which of the following factors would affect pain perception or tolerance for the laboring patient? A. Right occiput posterior fetal position during labor B. Bishop score of 10 prior to the induction of labor C. Gynecoid pelvis D. Absence of Ferguson's reflex

A. Right occiput posterior fetal position during labor A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Ferguson's reflex occurs when a contraction is stimulated as a result of vaginal stimulation.

When evaluating the patient's progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (Select all that apply.) A. baroreceptors. B. adrenal glands. C. chemoreceptors. D. uterine activity. E. autonomic nervous system.

A. baroreceptors. B. adrenal glands. C. chemoreceptors. E. autonomic nervous system. The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR, and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing accelerations in FHR. Hypertonic uterine activity can reduce the time available for the exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps.

A woman delivered a baby boy 30 minutes ago. The labor and delivery were uneventful. The nurse is assessing the woman's vital signs when the woman suddenly complains of chest pain and difficulty breathing. The vital signs show a decreased blood pressure and a slightly increased pulse. The nurse's next action should be to: A. call for assistance. B. have the woman sit up and assist her to take deep breaths to help her relax. C. administer pain medication D. increase the routine assessments to every 15 minutes until the vital signs stabilize.

A. call for assistance.

To determine if the patient is in true labor, the nurse would assess for changes in A. cervical dilation. B. amount of bloody show. C. fetal position and station. D. pattern of uterine contractions.

A. cervical dilation. Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor.

A nurse is reviewing the charts of antepartal patients. A 28-week-gestation woman's fetal fibronectin report has returned, with negative results. The nurse should A. document this report. B. notify the health care provider. C. document the need to do patient teaching on the signs of preterm labor during the woman's next visit. D. alter this woman's plan of care to include teaching about increasing protein intake in her diet.

A. document this report.

The patient is admitted in early labor. Her support person tells the nurse that the contractions have the following pattern: started 1232, ended 1233; started 1235, ended 1236; started 1239, ended 1240; started 1243, ended 1244. From this information, the nurse determines that the frequency of the contractions is A. every 3 to 4 minutes. B. every 2 to 3 minutes. C. lasting a minute. D. unable to be determined with this information.

A. every 3 to 4 minutes.

A labor patient has brought in a photograph of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of A. focal point. B. distraction. C. effleurage. D. relaxation.

A. focal point. The use of a focal point (image and/or point reference in the labor room) is an example of nonpharmacologic pain control during labor. The image of the patient's children is not serving as a method of distraction. Effleurage is the use of massage techniques to minimize pain perception. The image of the patient's children is not serving as a method of relaxation.

Excessive anxiety during labor heightens the patient's sensitivity to pain by increasing A. muscle tension. B. the pain threshold. C. blood flow to the uterus. D. rest time between contractions.

A. muscle tension. Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman's brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions.

After a planned cesarean section, the woman is being admitted back to the postpartum unit. The nurse notices that the patient is rubbing her nose and eyes continually. Being aware that the woman has been given epidural opioids, the nurse's next action should be to A. offer the woman some medication to relieve the itching. B. notify the anesthesiologist immediately. C. monitor for signs of respiratory depression. D. monitor the patient's temperature.

A. offer the woman some medication to relieve the itching.

A fetus is in the posterior position. The woman is complaining of back labor and the labor is prolonged. The nurse can best assist the mother with this problem by A. placing her in a hands and knees position. B. placing her in a prone position. C. massaging her back. D. encouraging her to use the whirlpool bath.

A. placing her in a hands and knees position.

Which physiologic event is the key indicator of the commencement of true labor? A. Bloody show B. Cervical dilation and effacement C. Fetal descent into the pelvic inlet D. Uterine contractions every 7 minutes

B. Cervical dilation and effacement The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

The health care provider for a laboring patient makes the following entry into the patient's record: 3/50%/+1. What instruction will the nurse implement with the patient? A. "You will need to remain in bed attached to the electronic fetal monitor." B. "Breathe with me slowly, in through your nose and out through your mouth." C. "I will begin the administration of 1000 mL of IV fluid so you can have an epidural." D. "Your partner will need to change into scrub attire to attend the imminent birth."

B. "Breathe with me slowly, in through your nose and out through your mouth." This patient is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at 1 station. Epidural placement during early labor may slow down the labor process and should be delayed. There is no indication that birth is imminent because the patient is only 3 cm dilated.

The primiparous patient at 39 weeks' gestation states to the nurse, "I can breathe easier now." What is the nurse's most appropriate response? A. "Your labor will start any day now since the baby has dropped." B. "That process is called lightening. Do you have to urinate more frequently?" C. "Contact your health care provider when your contractions are every 5 minutes for 1 hour." D. "You will likely not feel you baby's movements as much now, so do not be concerned."

B. "That process is called lightening. Do you have to urinate more frequently?" As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patient's statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure? A. Presenting part not engaged B. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c. Breech position of fetus d. Twin gestation

B. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) Amnioinfusion is a procedure utilized during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. An isotonic (Lactated Ringers or normal saline) solution is used as an irrigation method through the IUPC (intrauterine pressure catheter).

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.

A 39-week-gestation gravida 1 is 6 cm dilated. Membranes are intact. The labor contractions have decreased in intensity, and she has not dilated in the past 2 hours. A diagnosis of hypotonic dysfunctional labor has been made. The nurse can anticipate which of the following actions? A. Immediate cesarean section B. Amniotomy C. Narcotic administration D. Having her walk around

B. Amniotomy

A patient in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the patient. Which priority intervention should be performed in order to evaluate the clinical response to treatment? A. Obtain a pain scale response from the patient based on a 0 to 10 scale. B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. C. Document intake and output on the electronic health record (EHR). D. Increase the flow rate of prescribed parenteral fluid to maintain hydration.

B. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring patient but used for postoperative and/or chronic pain patients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this patient's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? A. Extension B. Engagement C. Internal rotation D. External rotation

B. Engagement Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

A laboring patient states to the nurse, "I have to push!" What is the next nursing action? A. Contact the health care provider. B. Examine the patient's cervix for dilation. C. Review with her how to bear down with contractions. D. Ask her partner to support her head with each push.

B. Examine the patient's cervix for dilation. When the cervix is completely dilated, the head can descend through the pelvis and stimulate the pushing reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

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

Which of the following laboring women is at highest risk for a prolapsed cord? All of the women have intact membranes and are cephalic presentations. A. Gravida 3, station +2, cervix 7 cm and 100% effaced B. Gravida 1, station -2, cervix 3 cm and 50% effaced C. Gravida 2, station 0, cervix 2 cm and 60% effaced D. Gravida 6, station 0, cervix 9 cm and 100% effaced

B. Gravida 1, station -2, cervix 3 cm and 50% effaced

You are preparing a patient for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) A. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. B. Have ephedrine available at bedside during catheter placement. C. Monitor blood pressure of patient frequently during catheter insertion and for the first 15 minutes of epidural administration. D. Insert a Foley catheter prior to epidural catheter placement. E. Monitor the patient for hypertension in response to epidural insertion.

B. Have ephedrine available at bedside during catheter placement. C. Monitor blood pressure of patient frequently during catheter insertion and for the first 15 minutes of epidural administration. A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is.

Which fetal position may cause the laboring patient increased back discomfort? A. Left occiput anterior B. Left occiput posterior C. Right occiput anterior D. Right occiput transverse

B. Left occiput posterior In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.

When administering a narcotic to a laboring patient, which statement explains why the nurse should inject the medication at the beginning of a contraction? A. The medication will be rapidly circulated. B. Less medication will be transferred to the fetus. C. The maternal vital signs will not be adversely affected. D. Full benefit of the medication is received during that contraction.

B. Less medication will be transferred to the fetus. Injecting the medication at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit of the medication will be received by the patient.

The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) A. Post-term fetus B. Maternal fever C. Placenta previa D. Induction of labor E. Prolonged rupture of membranes

B. Maternal fever C. Placenta previa E. Prolonged rupture of membranes Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may be used to evaluate a post-term fetus' response to stimulation. It is also used to evaluate a fetus when labor is being induced.

A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request? A. Maternal pulse B. Maternal temperature C. Maternal blood pressure D. Maternal blood glucose level

B. Maternal temperature A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool (jet hydrotherapy, or Jacuzzi). The major concern regarding immersion therapy has been newborn and postpartum maternal infections caused by microorganisms in the water. Infections can be caused by the woman's own ascending vaginal bacteria or by preexisting organisms in an improperly cleaned tub. Several studies have not found a significant association between newborn or postpartum maternal infections and the use of immersion hydrotherapy with proper cleaning.

A labor patient, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? A. Oxytocin (Pitocin) B. Naloxone (Narcan) C. Bromocriptine (Parlodel) D. Oxygen

B. Naloxone (Narcan) Because birth is imminent, and considering that the patient has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression.

The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.) A. Progesterone levels become higher than estrogen levels. B. Natural oxytocin in conjunction with other substances plays a role. C. Stretching, pressure, and irritation of the uterus and cervix increase. D. The secretion of prostaglandins from the fetal membranes decreases.

B. Natural oxytocin in conjunction with other substances plays a role. C. Stretching, pressure, and irritation of the uterus and cervix increase. Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor's initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time? A. Perform a vaginal exam to denote progress. B. Notify the health care provider. C. Initiate parenteral therapy. D. Apply oxygen via nasal cannula at 8 L/minute.

B. Notify the health care provider. A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a Caesarean section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the patient is in early labor; thus a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? A. On her back B. On her left side C. On her right side D. On her hands and knees

B. On her left side LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position.

The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents? (Select all that apply.) A. Citric acid (Bicitra) B. Ranitidine (Zantac) C. Hydroxyzine (Vistaril) D. Glycopyrrolate (Robinul) E. Promethazine (Phenergan)

B. Ranitidine (Zantac) C. Hydroxyzine (Vistaril) D. Glycopyrrolate (Robinul) To prevent aspiration of gastric contents during general anesthesia administration of medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra) and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine (Phenergan) are used to prevent and relieve nausea often associated with opioids.

Which nursing action is correct when initiating electronic fetal monitoring? A. Lubricate the tocotransducer with an ultrasound gel. B. Securely apply the tocotransducer with a strap or belt. C. Inform the patient that she should remain in the semi-Fowler position. D. Determine the position of the fetus before attaching the electrode to the maternal abdomen.

B. Securely apply the tocotransducer with a strap or belt. The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The patient should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus

Which statement correctly describes the nurse's responsibility related to electronic monitoring? A. Report abnormal findings to the physician before initiating corrective actions. B. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. C. Document the frequency, duration, and intensity of contractions measured by the external device. D. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

B. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. Teaching is an essential part of the nurse's role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures.

The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase? A. The patient is sociable and excited. B. The patient is requesting pain medication. C. The patient begins to experience the urge to push. D. The patient experiences loss of control and irritability.

B. The patient is requesting pain medication. During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? A. Early decelerations B. Variable decelerations C. Nonperiodic accelerations D. Increase in baseline variability

B. Variable decelerations When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes.

A laboring patient has asked the nurse to assist her in utilizing a cutaneous stimulation strategy for pain management. The nurse would A. assist her into the shower. B. apply a heat pack to lower back. C. help her to create a relaxing mental scene. encourage cleansing breaths and slow-paced breathing.

B. apply a heat pack to lower back. Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch, thermal stimulation, and acupressure. A shower, tub, and whirlpool are forms of hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing breaths and patterned breathing is part of breathing techniques for labor.

Childbirth pain is different from other types of pain in that it is A. less intense. B. associated with a physiologic process. C. more responsive to pharmacologic management. D. designed to make one withdraw from the stimulus.

B. associated with a physiologic process. Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; however, it is not caused by the type of injury as when withdrawal from the stimulus occurs.

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.

The nurse detects hypotension in a laboring patient after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) A. Encourage the patient to drink fluids. B. Place the patient in a Trendelenburg position. C. Administer a normal saline bolus as prescribed. D. Administer oxygen at 8 to 10 L/minute per face mask. E. Administer IV ephedrine in 5- to 10-mg increments as prescribed.

C. Administer a normal saline bolus as prescribed. D. Administer oxygen at 8 to 10 L/minute per face mask. E. Administer IV ephedrine in 5- to 10-mg increments as prescribed. If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The patient in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant patient.

The nurse is assessing the duration of a patient's labor contractions. Which method does the nurse implement to assess the duration of labor contractions? A. Assess the strongest intensity of each contraction. B. Assess uterine relaxation between two contractions. C. Assess from the beginning to the end of each contraction. D. Assess from the beginning of one contraction to the beginning of the next.

C. Assess from the beginning to the end of each contraction. Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment? A. Use contact anesthesia for an epidural and prepare the patient per protocol. B. Tell the patient that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. D. Call the physician for admitting orders.

C. Assist the patient with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. By assisting the patient with nonpharmacologic methods of pain distraction, the nurse is focusing on the patient's needs while still preparing for vaginal birth. The patient presents in an emergent situation with birth being imminent. Thus there is not enough time to administer an epidural. Telling the patient that she will not need any pain medication because the birth will be over soon does not address the patient's concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the patient. If needed, another nurse and/or supervisor can contact the physician.

The patient presenting at 38 weeks' gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for a late deceleration? A. Continue oxytocin (Pitocin) infusion. B. Contact the anesthesia department for epidural administration. C. Change maternal position. D. Administer Narcan to patient and prepare for immediate vaginal delivery.

C. Change maternal position. Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered to be a significant event requiring immediate assessment and intervention. Of all the options listed, changing maternal position may increase placental perfusion. In the presence of late decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural administration will not solve the existing problem of late decelerations. There are no data to support the administration of Narcan and because patient is still in early labor, birth is not imminent.

Which physiologic effect may occur in the presence of increased maternal pain perception during labor? A. Increase in uterine contractions in response to catecholamine secretion B. Decrease in blood pressure in response to alpha receptors C. Decreased perfusion to the placenta in response to catecholamine secretion D. Increased uterine blood flow, causing increase in maternal blood pressure

C. Decreased perfusion to the placenta in response to catecholamine secretion Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure.

The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? A. Every 10 minutes B. Every 15 minutes C. Every 30 minutes D. Every 60 minutes

C. Every 30 minutes Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage.

All of the following women in labor are requesting pain medication. To which one should the nurse administer an opioid analgesic first? A. Primigravida, 2 cm dilated, 50% effaced, grimacing slightly with each contraction B. Gravida 4, 9 cm dilated, 100% effaced, wants to push with each contraction C. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction D. Primigravida, 1 cm dilated, moans loudly with each contraction, has present history of heroin use

C. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction

Pregnant patients can usually tolerate the normal blood loss associated with childbirth because of which physiologic adaptation to pregnancy? A. A higher hematocrit B. Increased leukocytes C. Increased blood volume D. A lower fibrinogen level

C. Increased blood volume Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy due to the higher fluid volume. Leukocyte levels increase during labor; however, that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention at this time? A. Perform a vaginal exam to denote progress. B. Reposition the patient to a side lying position. C. Instruct the patient to breathe into her cupped hands. D. Notify the physician about current findings.

C. Instruct the patient to breathe into her cupped hands. This patient is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the patient to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the patient may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed.

Which statement is true with regard to the type of pain associated with childbirth experience? A. Pain is constant throughout the labor experience. B. Labor pain during childbirth is considered to be an abnormal response. C. Pain associated with childbirth is self-limiting. D. Pain associated with childbirth does not allow for adequate preparation.

C. Pain associated with childbirth is self-limiting. The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor.

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.

When admitting a client for induction of labor, the nurse will question the procedure if which of the following is on the client's prenatal record? A. Spontaneous rupture of membranes 24 hours ago, with no labor B. 42-week gestation C. Placenta previa D. Maternal heart disease that is worsening

C. Placenta previa

Which of the following is the priority intervention for a supine patient whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? A. Increase IV infusion. B. Elevate lower extremities. C. Reposition to left side-lying position. D. Administer oxygen per face mask at 4 to 6 L/minute.

C. Reposition to left side-lying position. Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the patient is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the patient is in a supine position.

If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? A. Right upper B. Left upper C. Right lower D. Left lower

C. Right lower If the fetus is in a right occiput anterior position, the fetal spine will be on the mother's right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case.

The nurse assesses a laboring patient's contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 seconds, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern? A. Stage 1, latent phase B. Stage 2, latent phase C. Stage 1, active phase D. Stage 2, active phase

C. Stage 1, active phase In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the pushing reflex (sometimes referred to as the Ferguson reflex). She is actively bearing down during the active phase of the second stage.

During the active stage of labor the woman is using a rapid "pant-blow" breathing pattern. She starts to complain of feeling dizzy and has some numbness in her fingers. The nurse's next action should be to A. notify the physician. B. do a vaginal exam to check for the progression of labor. C. have the woman breathe into a paper bag. D. offer pain medication.

C. have the woman breathe into a paper bag.

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.

Firm contractions that occur every 3 minutes and last 100 seconds may reduce fetal oxygen supply because they A. cause fetal bradycardia and reduce oxygen concentration. B. activate the fetal sympathetic nervous system. C. limit the time for oxygen exchange in the placenta. D. suppress the normal variability of the fetal heart.

C. limit the time for oxygen exchange in the placenta.

The method of anesthesia in labor that is considered the safest for the fetus is A. epidural block. B. pudendal block. C. local infiltration. d. spinal (subarachnoid) block.

C. local infiltration. Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension.

A primigravida is in the latent phase of labor and is at low risk for complications of labor. She asks the nurse if she may walk for a few minutes. The nurse is aware that this is (is not) possible because A. continuous fetal monitoring is required. B. continuous monitoring of the contractions is necessary at this stage of labor. C. intermittent auscultation of fetal heart rate is appropriate for her. D. there is no need to assess fetal heart rate at this early stage of labor.

C. may walk: intermittent auscultation of fetal heart rate is appropriate for her.

A woman who is about 37 weeks' gestation tells the nurse that for some reason this morning she can breathe easier. The nurse can best explain this as being a A. concern, and the fetus needs to be assessed. B. normal change toward the end of the pregnancy caused by a decreased use of oxygen by the fetus. C. normal change because of the fetus's dropping down into the pelvis region, relieving the pressure on her diaphragm. D. normal change caused by the maternal cardiac output increasing as she gets closer to labor.

C. normal change because of the fetus's dropping down into the pelvis region, relieving the pressure on her diaphragm.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is referred to as a(n) A. local. B. epidural. C. pudendal. D. spinal block.

C. pudendal. A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? A. Narcotics B. Spinal block C. Epidural anesthesia D. Breathing and relaxation techniques

D. Breathing and relaxation techniques Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there is probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

A patient in active labor requests an epidural for pain management. What is the nurse's most appropriate intervention at this juncture? A. Assess the fetal heart rate pattern over the next 30 minutes. B. Take the patient's blood pressure every 5 minutes for 15 minutes. C. Determine the patient's contraction pattern for the next 30 minutes. D. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hour over 30 minutes.

D. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hour over 30 minutes. Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer's or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.

The nurse is teaching a childbirth education class. Which information regarding excessive pain in labor should the nurse include in the session? A. It usually results in a more rapid labor. B. It has no effect on the outcome of labor. C. It is considered to be a normal occurrence. D. It may result in decreased placental perfusion.

D. It may result in decreased placental perfusion. When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed.

The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs between contractions. Which statement is the appropriate rationale for assessing maternal vital signs between contractions rather than at another interval? A. Vital signs taken during contractions are inaccurate. B. During a contraction, assessing fetal heart rate is the priority. C. Maternal blood flow to the heart is reduced during contractions. D. Maternal circulating blood volume increases temporarily during contractions.

D. Maternal circulating blood volume increases temporarily during contractions. During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

The nurse is concerned that a patient's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? A. Reposition the tocotransducer. B. Reposition the Doppler transducer. C. Obtain an order from the health care provider for a spiral electrode. D. Obtain an order from the health care provider for an intrauterine pressure catheter.

D. Obtain an order from the health care provider for an intrauterine pressure catheter. An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese patient, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR).

Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? A. Inhibition of epinephrine B. Inhibition of norepinephrine C. Stimulation of the vagus nerve D. Sympathetic stimulation

D. Sympathetic stimulation Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. The release of norepinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation and result in a decreased heart rate.

Childbirth preparation can be considered successful if which of the following outcomes is achieved? A. Labor was pain-free. B. The birth experiences of friends and families were ignored. C. Only nonpharmacologic methods for pain control were used. D. The patient rehearsed labor and practiced skills to master pain.

D. The patient rehearsed labor and practiced skills to master pain. Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realisticinformation about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone.

The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? A. This pattern reflects variable decelerations. No interventions are necessary at this time. B. Document this Category I fetal heart rate pattern and decrease the rate of the intravenous (IV) fluid. C. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply.

D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply. A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the patient on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a normal pattern, rather it is a Category III tracing, predictive of abnormal fetal acid status at the time of observation. The IV rate should be increased in order to add to the mother's blood volume. These are late decelerations, not early; therefore interventions are necessary.

When a pattern of variable decelerations occur, the nurse should immediately A. administer O2 at 8 to 10 L/minute. B. place a wedge under the right hip. C. increase the IV fluids to 150 mL/hour. D. position patient in a knee-chest position.

D. position patient in a knee-chest position. Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The patient should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression.

A major advantage of nonpharmacologic pain management is A. a more rapid labor is likely. B. more complete pain relief is possible. C. the woman remains fully alert at all times. D. there are no side effects or risks to the fetus.

D. there are no side effects or risks to the fetus. Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The woman's alertness is not altered by medication, but the increase in pain will decrease alertness.

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (late decelerations). Which is the most appropriate nursing action? a. Administer oxygen with a face mask at 8 to 10 L/minute. b. Reposition the fetal monitor ultrasound transducer. c. Assist the patient to the bathroom to empty her bladder. d. Continue to monitor the patient and fetal heart rate patterns.

a. Administer oxygen with a face mask at 8 to 10 L/minute. Late decelerations are similar to early decelerations in that the FHR slows (30 to 40 bpm); however, the decelerations are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/minute. The pattern is abnormal, so repositioning the fetal ultrasound transducer, assisting the patient to the bathroom, or continuing to monitor the pattern will not correct the problem.

Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area

a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent e. Vaginal elevation Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.

Immediately following the forceps-assisted birth of an infant, which action should the nurse implement? a. Assess the infant for signs of trauma. b. Apply a cold pack to the infant's scalp. c. Give the infant prophylactic antibiotics. d. Measure the circumference of the infant's head.

a. Assess the infant for signs of trauma. Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessment.

Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction

a. Complaint of pain between the scapulae A patient attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.

The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler b. Fetoscope c. Scalp electrode d. Tocodynamometer

a. Doppler Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions.

Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours

a. Elevated pulse rate An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.) a. Fetal death b. Postterm pregnancy c. Rupture of membranes at or near term d. Convenience of the patient or her health care provider e. Chorioamnionitis (inflammation of the amniotic sac)

a. Fetal death b. Postterm pregnancy c. Rupture of membranes at or near term e. Chorioamnionitis (inflammation of the amniotic sac) Fetal death, postterm pregnancy, rupture of members, and chorioamnionitis are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for convenience of the patient or her provider are not recommended; however, they have become common. Factors such as rapid labors and living a long distance from a health care facility may be a valid reason in such a circumstance.

The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The patient's understanding of the event

a. Fetal heart rate Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The patient's understanding of the event would only need to be documented if it presents a problem.

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time? a. Inform the mother that the fetal heart rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Suggest to the mother that she is going to have a boy because the heart rate is fast.

a. Inform the mother that the fetal heart rate is normal. The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations

a. Late decelerations Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal deceleration is not a recognized term.

Which clinical finding can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions

a. Variability Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques.

A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the patient with her hips slightly elevated.

a. Notify the health care provider promptly. Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.

The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and +2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and +2. What is the nurse's next action? a. Palpate the patient's bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.

a. Palpate the patient's bladder for fullness. The fetal presenting part is expected to descend at a minimal rate of 1 cm/hour in the nullipara and 2 cm/hour in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.

The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.) a. Powers b. Passage c. Position d. Passenger e. Psyche

a. Powers b. Passage d. Passenger e. Psyche Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor. Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman's ability to cope.Position is not one of the four Ps.

The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus b. Maternal temperature of 37.2C (99F) c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth

a. Soft boggy uterus c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean birth.

a. Stop the infusion of Pitocin. There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. If a Category II (indeterminate) or III (abnormal) tracing is interpreted, a prompt approach to assessing oxygenation should be completed.

During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the patient not to push until you prepare the vacuum extraction device for physician. d. Reposition the patient to facilitate birth.

b. Ask the physician if he or she would like you to prepare for a surgical method of birth. In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it may cause additional problems. Vacuum extraction will not help to resolve the birth issue and may lead to further complications. Repositioning of the patient may not be effective to relieve this condition and facilitate birth.

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2 C (99 F). What is the priority nursing action for this patient? a. Fetal acoustic stimulation b. Assess temperature every 2 hours c. Change absorption pads under her hips every 2 hours d. Review white blood cell count (WBC) drawn at admission

b. Assess temperature every 2 hours The woman's temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38C (100.4F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed.

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor

b. Clear with bits of vernix caseosa Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy? a. Continuous auscultation with a fetoscope b. Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour

b. Continuous electronic fetal monitoring Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications.

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.

b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. e. Remove wet linen as needed. Following birth, the newborn is at risk for hypothermia. Therefore nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour

b. Every 30 minutes For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern

b. Fetal distress A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and patients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure.

Which finding would be indicative of an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL

b. Heart rate of 122 bpm Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks' gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient's request? a. There is no way to tell if any complications would arise. Because the patient is not presenting with any problems, the nurse should call the health care provider and inform her or him of the patient's decision to go home and wait. b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the patient that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the patient will be sent home. d. Tell the patient that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physician's directions.

b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the patient wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore it is best for the patient to remain in a supervised clinical setting. Indicating that the patient could possibly go home would place the patient at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.

A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care? a. Administration of antihypertensive medication b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring

b. Initiation of CPR and other life support measures Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient with this condition will be hypotensive, not hypertensive.

Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor

b. Keeping underpads and linens as dry as possible Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

Which technique is least effective for the patient with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees

b. Lying supine and relaxing Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor.

b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. Nursing care of the normal laboring patient would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction

b. Painful uterine contractions c. Increased resting tone e. Increased uterine pressure Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus there is an increased risk for placental abruption as compared with placenta previa, which is based upon malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor.

Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor? a. Length of second-stage labor is 2 hours. b. Patient has received an epidural for pain control during the labor process. c. Patient is using breathing techniques during contractions to maximize pain relief. d. Patient is receiving parenteral fluids during the course of labor to maintain hydration.

b. Patient has received an epidural for pain control during the labor process. A patient who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.

b. Perform a vaginal examination. A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth? a. Presence of newborn reflexes b. Symmetry of facial movements c. Caput and molding of the head d. Anterior and posterior fontanels

b. Symmetry of facial movements Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infant's face.

Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth? a. Bloody mucous discharge increases. b. The vulva bulges and encircles the fetal head. c. The membranes rupture during a contraction. d. The fetal head is felt at 0 station during the vaginal examination.

b. The vulva bulges and encircles the fetal head. A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A zero station indicates engagement.

Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hour c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/minute

b. Urine output >30 mL/hour In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hour; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/minute may be indications of hypovolemia.

A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. last food intake, when labor began, and cultural practices the couple desires. d. identification of ruptured membranes, the woman's gravida and para, and access to a support person.

b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

A nursing priority during admission of a laboring patient who has not had prenatal care is a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care.

b. identifying labor risk factors. When a patient has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.

A maternal indication for the use of vacuum extraction is a. a wide pelvic outlet. b. maternal exhaustion. c. a history of rapid deliveries. d. failure to progress past 0 station.

b. maternal exhaustion. The patient who is exhausted will be unable to assist with the expulsion of the fetus. With a wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum extraction would not be necessary. A station of 0 is too high for a vacuum extraction.

A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent

c. Cesarean section The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the patient should be prepped for a cesarean section.

A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2 C (99 F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates

c. Cloudy amniotic fluid, with strong odor Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

Following an external cephalic version, which assessment finding indicates a complication? a. Onset of irregular contractions b. Maternal blood pressure of 110/70 mm Hg c. Deceleration of FHR to 88 bpm d. Maternal pulse rate of 100 bpm

c. Deceleration of FHR to 88 bpm A serious risk of external cephalic version is that the fetus may become entangled in the umbilical cord, compressing its vessels and resulting in hypoxia. The onset of irregular contractions, maternal blood pressure of 110/70 mm Hg, and maternal pulse rate of 100 bpm are normal findings.

The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant.

c. Document this evidence of normal early maternal-infant attachment behavior. Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a. External fetal monitoring (EFM) b. Internal fetal monitoring c. Intrauterine pressure catheter (IUPC) d. Maternal comments based on perception

c. Intrauterine pressure catheter (IUPC) IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the patient's own pain perception.

Proper placement of the tocotransducer for electronic fetal monitoring is a. Inside the uterus. b. On the fetal scalp. c. Over the uterine fundus. d. Over the mother's lower abdomen.

c. Over the uterine fundus. The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area.

While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider? a. Maternal pulse rate of 100 bpm b. Maternal blood pressure of 120/70 mm Hg c. Persistent fetal bradycardia below 100 bpm d. Decreased intensity of uterine contractions

c. Persistent fetal bradycardia below 100 bpm Fetal bradycardia may indicate fetal distress and may require immediate intervention. Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm Hg is within expected norms for this stage of labor. Decreased intensity of uterine contractions indicates the birth is imminent at this point.

Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/minute. b. Stop the Pitocin infusion. c. Position the patient in the knee-chest position. d. Increase the main line infusion to 150 mL/hour.

c. Position the patient in the knee-chest position. A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth? a. Anterior fontanel b. Coronal suture lines c. Posterior fontanel d. Biparietal diameter

c. Posterior fontanel The vacuum extractor is applied on the occipital bone and may create scalp edema at the application site. The posterior fontanel connects the occipital bone to the parietal bones. The anterior fontanel, coronal suture lines, and parietal bones are not part of the application area for a vacuum extractor.

After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency

c. Prolonged use of oxytocin Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.

A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase rate of Pitocin infusion to help spread out contraction pattern. b. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left side. c. Stop Pitocin infusion. d. Call physician to obtain an order for initiation of magnesium sulfate.

c. Stop Pitocin infusion. The patient is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop the infusion. The next course of action is to place oxygen on the patient and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be called for additional orders.

During contractions the fetus has mechanisms in place to protect it from the decrease in blood flow. Those mechanisms include a. fetal hemoglobin levels that are more resistant to oxygen. b. lower hemoglobin and hematocrit levels. c. a high cardiac output level. d. a higher respiratory level.

c. a high cardiac output level.

A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences a. increased fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus.

c. a trickle of fluid from the vagina. A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. Decreased or the lack of fetal movement requires further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

To clarify the fetal condition when baseline variability is absent, the nurse should first a. monitor fetal oxygen saturation using fetal pulse oximetry. b. notify the physician so that a fetal scalp blood sample can be obtained. c. apply pressure to the fetal scalp with a glove finger using a circular motion. d. increase the rate of nonadditive IV fluid to expand the mother's blood volume.

c. apply pressure to the fetal scalp with a glove finger using a circular motion. Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition.

A woman had premature rupture of the membranes at 37 weeks of gestation. She went into labor within 10 hours and delivered a 7 lb, 12 oz boy after a 12-hour labor. In planning care for the newborn, it is important to monitor him for A. respiratory distress syndrome. B. transient tachypnea of the newborn. c. infections. D. cardiac anomalies.

c. infections.

A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "Let me take off the monitor belts and help you get into a more comfortable position." c. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."

d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps." Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation.

Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous patient with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous patient at 39 weeks of gestation who is expecting twins

d. A multiparous patient at 39 weeks of gestation who is expecting twins Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this patient's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.

Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours. a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process

d. Anxiety related to imminent birth process A primipara is experiencing the birthing event for the first time and may experience anxiety due to fear of the unknown. It would be important to recognize this because the patient is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor patients includes the use of parenteral fluid therapy; the patient should be monitored for FVD and, if symptoms warrant, receive intervention. Because the patient has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara patient. Although the patient may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. The patient is entering the second stage of labor; therefore she will be allowed to push with contractions. In terms of pain management, medication will not be administered at this time because of imminent birth.

To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement? a. Monitor her urinary output. b. Maintain an intravenous infusion at 1 mL/hour. c. Assess the abdominal dressings for drainage. d. Assess the uterus for firmness every 15 minutes.

d. Assess the uterus for firmness every 15 minutes. Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.

After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma? a. Lack of an episiotomy b. Mild, intermittent perineal pain c. Lack of pain in the perineal area d. Edema and discoloration of the labia and perineum

d. Edema and discoloration of the labia and perineum The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe.

Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure

d. Fetal heart rate, maternal pulse, and blood pressure All assessments are important; however, those most relevant to tocolytic therapy include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication.

Which patient at term should proceed to the hospital or birth center the immediately after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours

d. Gravida 3, para 2, whose longest previous labor was 4 hours Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

The nurse is explaining the technique of internal version to a nursing orientee. Which statement best describes the technique of internal version? a. Manipulation of the fetus from a breech to a cephalic presentation before labor begins b. Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth c. Manipulation of the second twin from an oblique lie to a transverse lie before labor begins d. Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

d. Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal version is done to turn the second twin after the first twin is born.

Which clinical finding would be an indication to the nurse that the fetus may be compromised? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

d. Meconium-stained amniotic fluid When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

Which patient presentation is an acceptable indication for serial oxytocin induction of labor? a. Multiple fetuses b. Polyhydramnios c. History of long labors d. Past 42 weeks of gestation

d. Past 42 weeks of gestation Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus, making induction of labor high risk. Polyhydramnios also overdistends the uterus, creating a high risk for induction. A history of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances.

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (variable decelerations). Which is the most appropriate nursing action at this time? a. Decrease the rate of the IV fluids. b. Document the fetal heart rate pattern. c. Explain to the patient that the pattern is normal. d. Perform a vaginal exam to detect a prolapsed cord.

d. Perform a vaginal exam to detect a prolapsed cord. Variable decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. A vaginal examination may identify a prolapsed cord, which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal examination also evaluates the woman's labor status, which helps the birth attendant decide if labor should continue. This is a Category III tracing (abnormal); therefore the IV rate should be increased and an intervention needs to occur.

Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the patient for epidural administration as ordered by the physician

d. Preparing the patient for epidural administration as ordered by the physician The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.

Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at +3 station

d. Presenting part at +3 station If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.

A pregnant woman develops hypertension. The nurse monitors the patient's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow

d. Reduced placental blood flow Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.

Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.

d. Reposition the mother with her hips higher than her head. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete.

An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks' gestation and has two other children at home, ages 3 and 6. The patient's husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal? a. The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient's next scheduled antepartum visit the following week. b. The patient and husband will hire a nanny to act as an additional caregiver for the next month. c. The patient will continue to take care of her children at home, taking frequent rest periods. d. The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

d. The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified timeframe. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the patient to take care of her children at home with rest period because the patient will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.

The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent? a. The patient who has a Bishop's score of 5 b. The patient who is at 42 weeks of gestation c. The patient who had a previous low transverse cesarean birth d. The patient who had previous surgery in the upper uterus

d. The patient who had previous surgery in the upper uterus Prostaglandins are contraindicated in patients who have had a previous surgery in the upper uterus, such as a previous classic cesarean incision or extensive surgery for uterine fibroids. A side effect of prostaglandin administration is hyperstimulation of the uterus. A Bishop's score of 5, 42 weeks of gestation, or a previous low transverse cesarean birth are not contraindications for cervical ripening.

A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely a. a sign of abnormal labor progress. b. an indication that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor.

d. common during the transition phase of labor. The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be a. discharged home with a sedative. b. admitted for extended observation. c. admitted and prepared for a cesarean birth. d. discharged home to await the onset of true labor.

d. discharged home to await the onset of true labor. The situation describes a patient with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The patient will probably be discharged, and there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.