Chapter 14 PrepU

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." - Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR

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 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 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 nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

Fear of pain during 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.

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

Fetal status

The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?

Just before birth

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia 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 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.

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

administration of oxygen by mask

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 FHR.

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

determining the position of the fetus determining the presentation of the fetus determining the lie of the fetus

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate - Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

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 - In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

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

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 amount of cervical dilation.

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.

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?

The urge to push occurs.

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 most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

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 nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia."

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.

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

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventive. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventive.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

uterine atony - A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

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?

Meconium in the fluid

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?

Neonatal depression is possible. -General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

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 is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?

Check the chart for the last void.

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

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?

"I respect your preference, whether it is to have medication or not."

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." -Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

Which assessment findings of the fetus during labor are normal? Select all that apply.

-Variability between 18-20 bpm -Fetal heart baseline of 130 bpm Normal patterns suggest that the fetus is tolerating the labor. Both variability between 18-20 bpm and a baseline heart rate of 130 bpm are within normal limits. Both late and repeated variable decelerations are abnormal and may require further intervention. A gradual increase in the fetal heart rate baseline can signal a distressed fetus.

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

-distraction -pain relief without special tools -conscious relaxation

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 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

A client in labor has requested the administration of narcotics 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.

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 client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.

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.

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.

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.

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

Assess vital signs.

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. - At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

The nurse is caring for a client who is diagnosed with a postdural puncture (spinal) headache. When completing a nursing assessment, which position would exacerbate the symptoms?

Fowler position -A postdural puncture (spinal) headache occurs when the client is in an upright position and is relieved when the client is laying down and still. The nurse is correct to avoid placing the client in the Fowler or upright position. The other positions may be attempted to assess client symptoms.

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.

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. -To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

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 - In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

Which statement is true regarding analgesia versus anesthesia?

Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions.

While monitoring the EFM tracing the nurse notes decelerations with each contraction. The nurse knows that for a deceleration to be classified as early it has to meet three criteria. What is one of these criteria?

The nadir of the deceleration coincides with the acme of the contraction.

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.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

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

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 -The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR by Doppler at which frequency?

every 15 minutes

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 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

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels - During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

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. -The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia

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

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

prolonged decelerations - Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.