Chapter 14: Nursing Management During Labor and Birth

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 nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods.

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 stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs.

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

General

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?

It can be administered by the nurse.

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.

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

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

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you."

A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood?

"My baby's hips are flexed, and the knees are extended."

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 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

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority?

Blood pressure

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 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 multigravida client is in the late active phase of labor and asks for an opioid, stating they do not remember the pain being this bad in previous births. Which response from the nurse is best?

Pain medication can affect the baby's breathing; let's try to focus and breathe."

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?

Quickly evaluate the perineum.

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

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

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

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

conscious relaxation distraction pain relief without special tools

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness

A client received IV nalbuphine in labor. The labor progressed rapidly and the nurse is preparing for the birth of the neonate less than 1 hour later. What medication will the nurse ensure is available immediately after birth of the neonate?

naloxone

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply.

types of decelerations variability

At which time does the nurse anticipate that the primigravid client, G1P0, will need the most pain relief measures?

active phase (late) of the first stage of labor

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.

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 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.

A primigravida is 1 cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client? Select all that apply.

Simple breathing exercises Effleurage Walking and then using a birthing ball

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?

less anxiety

The nurse is reviewing a pregnant client's birth plan. The client asks the nurse about the use of opioids during the labor process. How will the nurse respond?

"You will feel less pain during the contractions, but will still feel some of the pain."

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Green-colored fluid in the vagina

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

Respiratory status