Chapter 10: Nursing Care during Labor and Birth

A woman is admitted to a labor unit in active labor. Which assessment would alert the nurse to the possibility that she may have difficulty accepting this child? "I'm so tired of being pregnant." "I haven't been able to sleep well lately." "I want this baby to be a boy." "I am so exhausted."

"I want this baby to be a boy."

A nurse is monitoring the fetal heart rate (FHR) of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention will the nurse implement? Encourage the Valsalva maneuver. Change maternal position to side-lying position. Administer exogenous oxytocin. Place the client in the lithotomy position.

Change the maternal position to side-lying position

A nursing instructor is conducting a session introducing a group of nursing students to the various pieces of equipment used for intermittent fetal monitoring. The instructor determines the session is successful after the students correctly choose which methods can be used? Select all that apply. Doppler fetoscope intrauterine pressure catheter external fetal monitor Leopold's palpation

Doppler fetoscope external fetal monitor

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 reports of feeling hungry and unsatisfied falling asleep from exhaustion expressions of satisfaction with her labor progress

Feelings of being frightened by the change in contractions

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? The client states that she is having heavy bleeding. When ambulating the client to the bathroom, a gush of red blood was noted. The client has saturated three sanitary napkins in the past 4 hours. The client has lost 100cc of blood from what I approximate on her clothing.

The client has saturated three sanitary napkins in the past 4 hours

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.

Turn her or ask her to turn on her side

Which method does the nurse use to determine fetal presentation, position and attitude? Assess location of fetal kicks View on an ultrasound Utilize Leopold maneuvers Complete a vaginal examination

Utilize Leopold maneuvers

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? at the level of the woman's umbilicus in the area above the woman's umbilicus in the woman's lower abdominal quadrant at the upper outer quadrant of the woman's abdomen

in the woman's lower abdominal quadrant

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? having the client breathe with contractions providing one-to-one support encouraging the woman to ambulate urging her to focus on one contraction at a time

Encouraging the woman to ambulate

Which action is a priority when caring for a woman during the fourth stage of labor? assessing the uterine fundus offering fluids as indicated encouraging the woman to void assisting with perineal care

Assessing the uterine fundus

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: yellow. olive green. pink. blue.

Blue

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

Baseline FHR

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement? "Nurses can influence birth outcomes in a positive way." "Anxiety can speed up the labor process." "Anxiety can slow down the labor process." "Continuous labor support can result in better labor outcomes."

"Anxiety can speed up the labor process."

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. 7.25 or more. 7.20. 7.21.

7.15 or less

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Urinalysis Vaginal examination Leopold maneuver Nonstress test

Vaginal examination

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? 10:05 a.m. 10:30 a.m. 11:15 a.m. 11:30 a.m.

10:30 a.m.

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique? "Inhale through your nose and exhale through pursed lips." "Inhale and exhale through your mouth about 4 times in 5 seconds." "Forcefully exhale every so often after inhaling and exhaling through your mouth." "Take a cleansing breath before but not after each contraction."

"Inhale through your nose and exhale through pursed lips."

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." "What would you like to eat?" "You can have a protein supplement." "I can get you something soft and easy to digest, like pudding."

"You could have some hard candy to suck on."

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Explain that you will have to call the physician and get an order to leave the fetal monitor off. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. Tell her that it is her decision, but that she will be placing herself and her baby at grave risk.

A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently

A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? Leakage from the perineum when the client coughs. Greenish fluid noted on the client's underwear A positive bacterial culture A positive Nitrazine test

A positive Nitrazine test

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. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. Begins with the time of placental delivery and ends when the healthcare provider is satisfied that there are no placental fragments. Begins with the time of placental delivery and ends 48 hours later.

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

A nurse notes the digital readings of the electronic fetal monitor shows decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus? Gastrointestinal system Musculoskeletal system Central nervous system Genitourinary system

Central nervous system

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? Check the fetal heart rate. Perform a vaginal exam. Notify the primary care provider immediately. Change the linen saver pad.

Check the fetal heart rate

In the labor and delivery unit, which is the best way to prevent the spread of infection? Use sterile gloves Limit vaginal examinations Complete hand hygiene Provide clean gloves in the room

Complete hand hygiene

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? Continue to monitor the client and the FHR Promptly inform the primary care provider Reposition the client Advocate for the client to have a vaginal examination

Continue to monitor the client and the FHR

Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would the nurse expect? does not hyperventilate uses accelerated breathing patterns continuously refrains from using the pant-blow technique so she doesn't push pants through each contraction as she pushes

Does not hyperventilate

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 5 minutes every 10 minutes every 15 minutes every 20 minutes

Every 15 minutes

Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply. Increase in bloody show The woman is more quiet and introverted The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur

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

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in? Perform a Fern test Inform the RN that your client may have ruptured membranes Check EFM for late decelerations Perform deep palpation of the client's abdomen

Inform the RN that your client may have ruptured membranes

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient? latent phase active phase transition phase none of the above

Latent phase

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? increased cervical dilation (dilatation) increased feelings of control less anxiety decreased sedation

Less anxiety

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? Check the pH to ensure the fluid is amniotic fluid. Prepare to administer an antibiotic. Notify the health care provider about possible meconium. Check the maternal heart rate.

Notify the health care provider about possible meconium

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Rubbing the client's legs Placing a wedge under the hips Providing a paper bag Massaging the client's lower back

Placing a wedge under the hips

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations prolonged decelerations early decelerations accelerations

Prolonged decelerations

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? notify the health care provider reposition the client on either side palpate for bladder fullness do nothing, this is benign

Reposition the client on either side

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? vaginal lacerations increased intracranial pressure cervical lacerations scalp edema

Scalp edema

A client comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is in which of the following stages of labor? first stage second stage third stage fourth stage

Second stage

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? tachypnea and a widening pulse pressure tachycardia and a falling blood pressure bradycardia and auscultation of fluid in the base of the lungs bradypnea and hypertension

Tachycardia and a falling blood pressure

The client may spend the latent phase of the first stage of labor at home unless which occurs? The client passes the bloody show The contractions vary in length and intensity The client begins back labor The client experiences a rupture of membranes

The client experiences a rupture of membranes

Which assessment finding is most important as labor progresses? The client is remaining in control of emotions. Labor is completed within 18 hours. The uterus relaxes completely between contractions. The pulse and respirations rise with the work of labor.

The uterus relaxes completely between contractions

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 beats/min The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. opioid medication to maternal client fetal movement fetal distress uteroplacental insufficiency maternal fever

fetal movement fetal distress uteroplacental insufficiency maternal fever

A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply. latent pre-labor active transition inactive

latent active transition

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? 5.0 5.5 6.0 6.5

6.5

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? "The warmth and buoyancy of the water has a nice relaxing effect." "I can stay in the bath for as long as I feel comfortable." "My cervix should be dilated more than 5 cm before I try using this method." "The temperature of the water should be at least 105℉ (40.5℃)."

"The temperature of the water should be at least 105℉ (40.5℃)."

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? intact membranes cervical dilation (dilatation) of 2 cm or more floating presenting fetal part a neonatologist to insert the electrode

Cervical dilation (dilatation) of 2 cm or more

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done? infection premature birth breech delivery prolonged labor

Infection

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? A blood culture to note any infection of the blood A urine culture to rule out a urinary tract infection An ultrasound to determine fetal age A urine dipstick test to check for protein

A urine dipstick test to check for protein

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. Notify the registered nurse. Notify the health care provider. Wait 2 minutes to review another tracing.

Assess and reposition the woman

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Test a sample of amniotic fluid for protein. Ask her to bear down with the next contraction. Elevate her hips to prevent cord prolapse. Assess fetal heart rate for fetal safety.

Assess fetal heart rate for fetal safety

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first? Assess the fetal heart rate Assess the strength of contraction Assess if the bladder is distended Assess the client's psyche

Assess if the bladder is distended

It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following? consistent early accelerations, variability present, and occasional decelerations flat line without variability and no decelerations occasional mild variable decelerations and moderate variability present deep variable decelerations more than 60 bpm below the baseline with every contraction

Deep variable decelerations more than 60 bpm below the baseline with every contraction

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 alleviating perineal discomfort with the application of ice packs palpating the woman's fundus for position and firmness completing the identification process of the newborn with the mother

Encouraging the woman to push when she has a strong desire to do so

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 fetal head fetal shoulders fetal buttocks

Fetal back

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a shallow deceleration occurring with the beginning of contractions variable decelerations, too unpredictable to count fetal baseline rate increasing at least 5 mm Hg with contractions fetal heart rate declining late with contractions and remaining depressed

Fetal heart rate declining late with contractions and remaining depressed

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply. frequency duration status of membranes intensity activity of fetus

Frequency Duration Intensity

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? Have the client lightly push to meet the need. Have the client pant and blow through the contraction. Have the client divert the energy to squeezing a hand. Assist the client to a Fowler position.

Have the client pant and blow through the contraction

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Help the woman change positions. Obtain assistance to check for a compressed umbilical cord. Prepare the woman for an emergency cesarean birth. Document the finding.

Help the woman change positions

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? Providing pain relief for the mother Koala care Making sure the significant other holds the infant shortly after birth Kangaroo care

Kangaroo care

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 right side of the abdomen At the level of the umbilicus On the uterine fundus Midline but low on the abdomen

On the uterine fundus

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? boggy, soft uterus uterus becoming discoid shaped sudden gush of dark blood from the vagina shortening of the umbilical cord

Sudden gush of dark blood from the vagina

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place? The uterus relaxes between contractions. The uterus contracts and squeezes the cord against the fetus. prematurity fetal sleep

The uterus contracts and squeezes the cord against the fetus

At what time is the laboring client encouraged to push? When the nurse wants the client to push When the health care provider has arrived When the cervix is fully dilated When the fetal head can be seen

When the cervix is fully dilated

A patient arrives at the birthing suite and tells the nurse that she believes she is in labor. Which assessments should the nurse prioritize at this time? Select all that apply. birth imminence fetal status risk factors labor preferences maternal status birth preferences

birth imminence fetal status risk factors maternal status

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? intense strong moderate mild

moderate