Chapter 14

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.

• Administer oxygen by mask • Assess client for underlying causes • Turn the client on her left side

A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?

Taking her blood pressure and determining whether clonus or edema is present

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

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 • intensity

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

Administration of oxygen by mask

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 dilation

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

What is the normally accepted fetal heart rate range?

110-160 bpm

Your client is in active labor. When you check the EFM tracing, you note variables that are nonreassuring. What would be your first nursing intervention?

Help the woman change positions

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

Initiate the technique only when the client is in active labor

The nurse explains Leopold's 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

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

Acme

A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which of the following interventions should the nurse implement?

Change maternal position to an upright or side lying position

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive assessment that uterine contractions are effective would be:

Dilatation of cervix

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate (FHR) with the Doppler at least how often?

Every hour

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

A pregnant client in her 32nd week of gestation has been admitted to a health care center with complaints of decreased fetal movement. Which of the following should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?

Fetal back

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

Fetal heart rate declining late with contractions and remaining depressed

During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent and the baseline FHR is within normal limits. What should you do first?

Help the woman change positions

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next?

Notify the healthcare provider

Mrs. Timms is a G1 P0. She is in active labor. One of your nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder." What would be an appropriate nursing action in achieving the goal of "no complications due to a full bladder"?

Palpate the area above the symphysis pubis every two hours

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?

Placenta previa

What is the most important thing that you can do during labor and delivery to prevent maternal and fetal infection?

Thoroughly wash your hands before and after patient contact

If the monitor pattern of uteroplacental insufficiency were present, which of the following would you do first?

Turn her or ask her to turn to her side

The nurse encourages a woman in labor to ambulate based on the understanding that it helps with which of the following? Select all that apply.

• Enlists the aid of gravity to move the fetus • Enhances the effectiveness of contractions • Increases the urge to push during the second stage • Encourages rotation of the fetus • Helps the fetus line up with the angle of the pelvis

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

Assess fetal heart rate for fetal safety.

During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus how often?

Every 15 mins

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 Active Transition

The student nurse is preparing to assess the fetal heart rate (FHR). She 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

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

Lower quadrant of the maternal abdomen

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

Prolonged decelerations

A woman arrives in labor and delivery, is panting and screaming "the baby is coming". What is the priority intervention by the nurse?

Quickly move the woman to a labor bed, check the perineum

Which of the following signs signify that the second stage of labor has begun?

The urge to push occurs