prep u chapter 14
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?
Massage the woman's back.
Category I FHR
Normal. - baseline rate 110-116 bpm - baseline FHR variablility: moderate - late or variable decelerations: absent - early decelerations: present or absent
After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client?
Simple breathing exercises Effleurage Walking and then using a birthing ball
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth
decreased alertness
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?
encouraging the woman to push when she has a strong desire to do so
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes
The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR by Doppler at which frequency?
every 15 minutes
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed
minimal
fluctuation range observed at <5 beats per minute
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
moderate
normal fluctuation range from 6 to 25 beats per minute
the best position to auscultate fetal heart tones
on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?
rupture of membranes
What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?
starting an IV and hanging IV fluids
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver.
so the membranes are probably ruptured if the pH ranges from
6.5 to 7.5.
n the hypoxic fetus, the pH will fall below
7.2, which is indicative of fetal distress.
When explaining why general anesthesia is rarely used, which information would the nurse include?
A pregnant woman has a risk for vomiting and aspiration. General anesthesia readily crosses the placenta.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
Fetal status
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
Inability to push
When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching
You have no trouble walking around and using the bathroom after you receive the epidural."
Effleurage
is light fingertip repetitive abdominal massage
During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?
ischial spine
The nurse should provide what if a client who has been administered combined spinal-epidural analgesia exhibits signs of hypotension and associated FHR changes
supplemental oxygen
An increase in the FHR (tachycardia) from the baseline can mean
that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency.
Late decelerations are associated with
uteroplacental insufficiency
A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response?
"Spinal headache is not a usual complication of epidural blocks."
Marked variability
>25 bpm
Category III FHR
Abnormal tracing - predictive of abnormal fetal acid base status at time of observation; requires prompt eval and intervention
The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?
acupressure
Cord compression would be marked by
fetal tachycardia.
Promethazine
used in combination with an opioid to decrease nausea and vomiting and lessen anxiety
There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?
Neonatal depression is possible
absent
fluctuation range undetectable
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman.
A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?
Continue to massage the client's fundus.
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point?
Counterpressure against the sacrum
Which symptoms indicate that the client has begun the transition phase of labor?
Increase in bloody show The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur
category II fhr
Indeterminate. Require continued observation.
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?
Just before birth
The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension?
Priming tubing for initiating a fluid bolus
Which statement is true regarding analgesia versus anesthesia?
Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn.
The pain of labor is influenced by many factors. What is one of these factors?
The woman is prepared for labor and birth
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status
Variable decelerations often indicate
a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?
respiratory depression
The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take
Determine presentation. Determine position. Confirm presentation. Determine attitude.
Which nursing action is applied throughout all stages of labor?
Do not allow the client to lay flat on her back for long periods.
The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next?
Notify the health care provider.
Patterned breathing techniques used in labor provide which benefits?
conscious relaxation distraction pain relief without special tools
What must the nurse do before the woman receives the epidural?
Administer a fluid bolus through the IV line to reduce the risk of hypotension.
