Ch. 14 Nursing mgmt during labor

The labor nurse reports to the nurse on the oncoming shift, "The woman in labor room 2 is handling her pain very well. She smiles whenever I go in to talk to her, and she doesn't complain at all!" What assessment by the oncoming labor nurse would best reveal if the off-going labor nurse's observations were correct?

Asking the woman to describe her pain and rate it on a scale of 0 to 10

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

Assess fetal heart rate.

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

Assess vital signs.

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

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

Practicing effleurage on the abdomen

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the client to push when they have a strong desire to do so

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

As a woman enters the second stage of labor, which would the nurse expect to assess?

feelings of being frightened by the change in contractions

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back

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.

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

left lower quadrant.

Which medication is administered to reverse the depressant effects of opioids?

naloxone

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

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."

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."

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time."

The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?

"The fever may be due to the epidural."

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

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

The nurse 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 to 160 bpm

The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first?

Assess blood pressure.

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.

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

Feelings of control are inversely related to the client's report of pain.

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.

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 provider.

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

the presentation, lie, and attitude of the fetus.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain."

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first."

Patterned breathing techniques used in labor provide which benefits? Select all that apply.

* conscious relaxation * distraction * pain relief without special tools

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.

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

Acceleration of at least 15 bpm for 15 seconds

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes

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.

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.

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

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.

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

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 nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment

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 why she cannot receive any pain medication.

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

The woman is prepared for labor and birth.

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.

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first?

Feel for the fetal buttocks or head while palpating the abdomen.

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation?

General

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction.

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 the technique only when the client is in active labor.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

On the uterine fundus

A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"?

Palpate the area above the symphysis pubis every 2 hours.

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

Placing a wedge under the hips

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

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

This may prolong labor and increase complications.

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

Thoroughly wash the hands before and after client contact.

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 client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?

Use a birthing ball and find a position of comfort.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

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.

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

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

effleurage.

At which time interval will the nurse assess the fetal heart rate of pregnant clients who are in the early active phase of labor?

every 15 to 30 minutes

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

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

fetal heart rate declining late with contractions and remaining depressed

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?

general anesthesia

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize?

increased variability

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

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

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.

On examination, the nurse determines the client is at 50% effacement. This means:

the cervical canal is 1 cm long.

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."

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.

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

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

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