306 Ricci Chapter 14: Nursing Management During Labor and Birth

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. Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize?

Take blood pressure and determine if clonus or edema are present. In advanced labor, the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first, which would include the assessment of her blood pressure and presence of clonus or edema. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

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 During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

How does a woman who feels in control of the situation during labor influence her pain?

feelings of control are inversely related to client reports of pain Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

it distracts your brain from the sensations of pain Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next Measuring from the beginning of one contraction to the next marks the time between contractions.

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on" The woman can be encouraged to sip fluid, ice chips, or suck on hard candy if she becomes thirsty or nauseated by labor. It also helps to supply extra fluid. Although many hospital protocols dictate that women who present in labor should not partake of oral nutrition, there is little evidence to support this restrictive practice. However, if women are kept NPO during labor, they can be administered anesthesia safely in an emergency.

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

difficulty breathing Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.

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 Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the opioid or reduce anxiety.

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 The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

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

the client experiences a rupture of membranes Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

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 with contractions and remaining depressed Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

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

instruct the client or her partner to perform light fingertip repetitive abdominal massage Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique.

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 Pudendal block is a local block in the perineal area and is used to numb for birth. Giving a pudendal block before labor begins or while labor is in its early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over.

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

accelerations of at least 15 bpm for a 15 seconds A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.

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 Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

vaginal examination A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.

The pain of labor is influenced by many factors. What is one of these factors?

the woman is prepared for labor and birth The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

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

assess fetal heart rate After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.

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 prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventive. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventive.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

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

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

encourage her through the contractions, explaining to her why she cannot receive any pain medication At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

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 It is recommended that the FHR be assessed during the second stage of labor every 5-15 minutes min by Doppler or continuously by EFM.

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

The nurse is monitoring the electronic fetal heart rate monitor and notes the following: variable V-shaped decelerations in the fetal heart rate (FH)R lasting about 30 seconds, accelerations of about 5 beats/min before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize?

help the woman change positions The electronic fetal heart rate monitor reading is associated with cord compression. Changing to a different position is a first intervention to determine if this will improve the oxygen to the fetus. Supplemental oxygen should be maintained until the mother is stable. Pharmacologic interventions are premature. The nurse should modify pushing in the second stage of labor to improve fetal oxygenation.

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 If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

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 Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as 0 station.

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 utters due to compression of blood vessels During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

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

maternal hypotension and fetal bradycardia Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?

naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If an opioid is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

palpate the mothers radial pulse at the same time To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

practice effleurage on the abdomen In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

turn her or ask her to turn to her side The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

uterine resting tone frequency of contractions intensity of contractions The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?

uteroplacental insufficiency Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"the injection if given outside the space from the spinal cord" An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

assess the amount of cervical dilatation (dilatation) If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation (dilatation). Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

110-160 BPM The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?

effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Women identify being involved in their pain management and adequate control of their pain as important factors in their overall labor experience. Women often report that it is not the amount of pain they have during labor that contributes to a satisfactory birth experience but rather how their pain is managed.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

assess fetal heart rate for fetal safety Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?

change the position of the client 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 gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

clear to straw colored fluid The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

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 During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

inhale slowly through the nose and exhale through purses lips For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-pace breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every three breaths is not recommended in any of the three levels of patterned breathing.

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?

initiate this technique only when the client is in active labor The recommendation for initiating hydrotherapy is that women be in active labor (>5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. The woman's membranes can be intact or ruptured.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

support the client's decision and call the obsteritian Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

While monitoring the EFM tracing the nurse notes decelerations with each contraction. The nurse knows that for a deceleration to be classified as early it has to meet three criteria. What is one of these criteria?

the nadir of the deceleration coincides with the acme of the contraction Three criteria classify the deceleration as early: (1) the FHR begins to slow as the contraction starts; (2) the lowest point of the deceleration, the nadir, coincides with the acme (highest point) of the contraction; and (3) the deceleration ends by the end of the contraction.

A woman's perception of pain can differ according to all of the following except:

the presentation, lie, and attitude of the fetus Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?

the urge to push occurs Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.

Which assessment finding is most important as labor progresses?

the uterus completely relaxes between contractions It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.

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

assess vital signs The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver?

fetal presentation Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluxuates from 6-25 beats per minute Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?

endorphins The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.