Chapter 14

A woman dilated to 10 centimeters and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?

Pudendal block

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 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.

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

Vaginal examination

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 nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment.

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 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

The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby?

1 cm below the ischial spine.

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

General

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

Complete hand hygiene

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?

Counter pressure against the sacrum

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

Determine if the client is in true or false labor.

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.

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 nose and exhale through pursed lips.

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 mother's radial pulse at the same time.

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 obstetrician.

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

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

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."

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

Baseline fetal heart rate

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

ACME

A nurse is assessing her female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor?

The cervix has changes of effacement and dilatation.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical 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.

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

he nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, 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

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.

Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38 ℃ (100.4 ℉). Answer questions and encourage verbalization of fears.

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

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?

10:30 a.m.

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 reassuring based on which recording?

Acceleration of at least 15 bpm for 15 seconds

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

Anxiety can slow down labor and decrease oxygen to the fetus.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression.

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 preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication?

Continuous support through the labor process helps decrease the need for pain medication.

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.

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

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 nurse is meeting with a client to develop the nursing care plan for her delivery to include the use of an injectable pain medication. When comparing the various options for the client, which advantage of using an intrathecal anesthesia over an epidural anesthesia should the nurse point out?

Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia.

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

The nurse is correct to instruct the active labor client on which type of patterned breathing?

Transitioning breaths from "slow, deep breaths to quicker short breaths" at the contraction peak.

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.

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

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. It would be most appropriate to meet which criterion?

rupture of membranes