Chapter 8 Intrapartum Assessment and Interventions

A common side effect of epidural anesthesia in labor includes A. Maternal hypotension B. Maternal hypertension C. Variable decelerations in the FHR D. Hypertonic labor pattern

A. Maternal hypotension

A woman you are caring for in labor requests an epidural for pain relief in labor. Included in your preparation for epidural placement is a baseline set of vital signs. The most common vital sign to change after epidural placement: A. Blood pressure, hypotension B. Blood pressure, hypertension C. Pulse, tachycardia D. Pulse, bradycardia

ANS: A Blood pressure, hypotension, as up to 40% of women may experience hypotension. Hypotension is defined as systolic BP <100 mm Hg or 20% decrease in BP from preanesthesia levels. Intravenous bolus is typically given to decrease the incidence of hypotension.

A woman is considered in active labor when: A. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. B. Cervical dilation progresses to 3 cm with effacement of 30, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. C. Cervical dilation progresses to 8 cm with effacement of 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. D. Cervical dilation progresses to 10 cm with effacement of 90%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.

ANS: A Characteristics of this phase are the cervix dilates, on an average, 1.2 cm/hr for primiparous women and 1.5 cm/hr for multiparous women. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%. Fetal descent continues and contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds, and discomfort increases.

Mrs. H is telling you she feels the urge to push. This is most likely caused by what? A. Low fetal station triggering the Ferguson reflex B. A fetal position of occiput posterior (OP) C. The second stage of labor D. Latent phase

ANS: A Once the cervix is fully dilated and the vertex is low in the pelvis and the woman feels the urge to push, she will involuntarily bear down. This is activated when the presenting part as it descends stretches the pelvic floor muscles and triggers the Ferguson reflex.

The provision of support during labor has demonstrated that women experience a decrease in anxiety and a feeling of being in more control. In clinical situations, this has resulted in: A. A decrease in interventions B. Increased epidural rates C. Earlier admission to the hospital D. Improved gestational age

ANS: A Studies have shown that with a support person, be it a family member, friend, or professional such as a Doula or nurse, the patient experiences a decrease in anxiety and has a feeling of being in more control. This, in turn, results in a decrease in interventions, a significantly lower level of pain, and an enhanced overall maternal satisfaction.

Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? A. Increasing abdominal girth measurements B. Profuse vaginal bleeding C. Bradycardia with an aortic thrill D. Hypothermia with chills

ANS: A The nurse would expect to see increasing abdominal girth measurements.

The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (Select all that apply): A. Cocaine use B. Tobacco use C. Previous caesarean birth D. Previous use of medroxyprogesterone (Depo-Provera)

ANS: A, B, C Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age.

The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided about preterm labor and birth prevention includes (Select all that apply): A. Encouraging regular, ongoing prenatal care B. Reporting symptoms of urinary frequency and burning to the health-care provider C. Coming to the labor triage unit if back pain or cramping persist or become regular D. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes

ANS: A, B, C The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. Educating all women of childbearing age about preterm labor is a crucial component of prevention.

The perinatal nurse describes for the new nurse the various risks associated with prolonged premature preterm rupture of membranes. These risks include (Select all that apply): A. Chorioamnionitis B. Abruptio placentae C. Operative birth D. Cord prolapse

ANS: A, B, D Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged ROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks' gestation. An appropriate nursing action would be to (Select all that apply): A. Assess the fetal heart rate B. Obtain urine for culture and sensitivity C. Assess Kerry's blood pressure and pulse D. Palpate Kerry's abdomen for contractions

ANS: A, B, D Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient's abdomen should be palpated to assess for contractions, and the fetus's heart rate should be monitored. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency).

It would be most important for a nurse caring for a mother and the infant in the fourth stage of labor to do which of the following? (Select all that apply) A. Assess and massage the fundus every 15 minutes or more often if needed B. Massage the uterus continuously C. Administer oxytocin per protocol D. Assess the patient for a distended bladder

ANS: A, C, D The fourth stage of labor immediately follows the delivery of the placenta. The nurse should be assessing the fundus every 15 minutes for position, tone, and location. The provider may order oxytocin at this stage, and the nurse should assist the woman to the bathroom if she has a distended bladder which could interfere with the contraction of the uterus.

The mechanism of labor known as cardinal movements of labor are the positional changes that the fetus goes through to best navigate the birth process. These cardinal movements are: A. Engagement, Descent, Flexion, Extension, Internal rotation, External rotation, Expulsion B. Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion C. Engagement, Flexion, Internal rotation, Extension, External rotation, Descent, Expulsion D. Engagement, Flexion, Internal rotation, Extension, External rotation, Flexion, Expulsion

ANS: B Engagement occurs when the greatest diameter of the fetal head passes through the pelvic inlet. Engagement can occur late in pregnancy or early in labor. Descent is the movement of the fetus through the birth canal during the first and second stages of labor. Flexion is when the chin of the fetus moves toward the fetal chest. Flexion occurs when the descending head meets resistance from maternal tissues. This movement results in the smallest fetal diameter to the maternal pelvic dimensions. It typically occurs early in labor. Internal rotation is the movement, the rotation of the fetal head, that aligns the long axis of the fetal head with the long axis of the maternal pelvis. It occurs mainly during the second stage of labor. Extension is the movement facilitated by resistance of the pelvic floor, causing the presenting part to pivot beneath the pubic symphysis and the head to be delivered. This occurs during the second stage of labor. External rotation is when the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis. Expulsion is the movement that occurs when the shoulders and remainder of the body are delivered.

A low-risk patient calls the labor unit and says "I need to come in to be checked right now, there were pink streaks on the toilet paper when I went to the bathroom. I think I'm bleeding." What response should the nurse say first? A. "How much blood is there?" B. "You sound concerned, what other labor symptoms do you have? C. "Don't worry that sounds like a mucus plug." D. "Does it burn when you urinate?"

ANS: B The nurse is using reflection to acknowledge the woman's concerns and asks for further assessment. The woman's fear must first be acknowledged and then other questions or comments can be made.

A labor nurse is caring for a patient, 39 weeks' gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? A. Type and cross-match her blood. B. Insert an internal fetal monitor electrode. C. Administer an oral stool softener. D. Assess her complete blood count.

ANS: B This action is inappropriate. When a patient has a placenta previa, nothing should be inserted into the vagina.

Ms. M is 38 weeks' gestation and is a G1 P0. At 10 pm Ms. M has just been informed by the nurse that she is 3 to 4 cm dilated, cervix is 100% effaced, and contractions are every 4 to 5 minutes. When the nurse tells her the findings from the SVE, Ms. M states that she had been contracting since early that morning and she becomes extremely frustrated stating "I should have had this baby by now." What is the best response by the nurse? A. Remind her that length of labor for the first child can be 18 to 24 hours B. Promote relaxation techniques C. Discuss various analgesic options D. Tell Ms. M that the provider will be contacted immediately about the slow progress of labor

ANS: B Women in the latent phase of labor may be frustrated with lack of progress or slow progress of labor and desire companionship and encouragement. The other responses are inappropriate. The nurse should first encourage breathing and relaxation methods as well as provide reassurance, and then contact the provider.

The labor patient you are caring for is ambulating in the hall. Her vaginal exam 1 hour ago indicated she was 4/70/-1 station. She tells you she has fluid running down her leg. Your priority nursing intervention is to: A. Assess the color, odor, and amount of fluid. B. Assist your patient to the bathroom. C. Assess the fetal heart rate. D. Call the care provider.

ANS: C Assessing the fetal heart rate is the first priority because of the risk of umbilical cord prolapse with rupture of membranes.

You are caring for a woman in labor who is 6 cm dilated with a reassuring FHR pattern and regular strong uterine contractions. The fetal heart rate (FHR) should be: A. Monitored continuously B. Monitored every 15 minutes C. Monitored every 30 minutes D. Monitored every 60 minutes

ANS: C Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring FHR is indicated every 30 minutes.

In caring for a primiparous woman in labor, one of the factors to evaluate is uterine activity. This is referred to as the __________ of labor. A. Passenger B. Passage C. Powers D. Psyche

ANS: C Powers refer to the contractions.

A woman who is admitted to labor and delivery at 30 weeks' gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? A. Temperature B. Pulse C. Respiratory rate D. Blood pressure

ANS: C The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity.

A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings? A. Pyelonephritis B. Pregnancy-induced hypertension C. Gestational diabetes D. Abruptio placentae

ANS: C Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies.

The perinatal nurse knows that tocolytic agents are most often used to (Select all that apply): A. Prevent maternal infection B. Prolong pregnancy to 40 weeks' gestation C. Prolong pregnancy to facilitate administration of antenatal corticosteroids D. Allow for transport of the woman to a tertiary care facility

ANS: C, D Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of antenatal corticosteroids to accelerate fetal lung maturity. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensive care unit.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestation in her first pregnancy. She is worried about having her baby "too soon," and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: A. Preterm labor B. Term labor C. Back labor D. Braxton-Hicks contractions

ANS: D Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? A. Serum potassium level increases B. Diarrhea C. Urticaria D. Complaints of nervousness

ANS: D Complaints of nervousness are commonly made by women receiving subcutaneous beta agonists.

Ms. P has delivered her first baby 30 minutes ago and the placenta delivered 15 minutes ago. She is attempting to breastfeed her newborn daughter for the first time. Which action by the nurse would NOT be appropriate? A. The nurse is checking the BP every 15 minutes B. The nurse is massaging the fundus vigorously C. The nurse is auscultating the infant's heart and lungs while on the mother's chest D. The nurse is leaving the patient unattended for 30 minutes to bond with her newborn

ANS: D During the fourth stage of labor the mothers should not be left unattended as maternal bleeding needs to be closely monitored.

Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa? A. "During the second stage of labor you will need to bear down." B. "You should ambulate in the halls at least twice each day." C. "The doctor will likely induce your labor with oxytocin." D. "Please promptly report if you experience any bleeding or feel any back discomfort."

ANS: D Labor often begins with back pain. Labor is contraindicated for a patient with complete placenta previa. This patient will need to deliver their baby via C-section.

The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? A. The patient with placenta previa B. The patient whose vagina is colonized with group B streptococci C. The patient who is hepatitis B surface antigen positive D. The patient with eclampsia

ANS: D Patients with eclampsia are high risk for placental abruption.

You are in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 4/70/0. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to: A. Reassure the patient and rapidly complete the admission. B. Assist your patient to the bathroom to have a bowel movement. C. Assess the fetal heart rate and uterine contractions. D. Perform a vaginal exam.

ANS: D Perform a vaginal exam to assess the progress of labor. The urge to have a bowel movement and feeling like pushing indicate that birth may be imminent.

The Apgar score consists of a rapid assessment of five physiological signs that indicate the physiological status of the newborn and includes: A. Apical pulse strength, respiratory rate, muscle flexion, reflex irritability, and color B. Heart rate, clarity of lungs, muscle tone, reflexes, and color C. Apical pulse strength, respiratory rate, muscle tone, reflex irritability, and color of extremities D. Heart rate, respiratory rate, muscle tone, reflex irritability, and color

ANS: D The Apgar score includes assessment of heart rate based on auscultation, respiratory rate based on observed movement of chest, muscle tone based on degree of flexion and movement of extremities, reflex irritability based on response to tactile stimulation, and color based on observation.

A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? A. Postpartum hemorrhage B. Neonatal hyperglycemia C. Postpartum oliguria D. Neonatal macrosomia

ANS: D The nurse would expect to see neonatal macrosomia.

When caring for a primiparous woman being evaluated for admission for labor, a key distinction between true versus false labor is: A. True labor contractions result in rupture of membranes, and with false labor, the membranes remain intact. B. True labor contractions result in increasing anxiety and discomfort, and false labor does not. C. True labor contractions are accompanied by loss of the mucus plug and bloody show, and with false labor there is no vaginal discharge. D. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

ANS: D True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

Nurses manage the care of patients receiving regional anesthesia A. True B. False

B. False

Supportive activities in labor are? A. Interventions ordered by the care provider B. Techniques used to help women in labor C. Derived from adhering to the birth plan D. Pharmacological interventions

B. Techniques used to help women in labor

Labor pain in active labor is primarily caused by A. Cervical dilation B. Uterine contractions C. Fetal descent D. Perineal tearing

B. Uterine contractions

Women who have a support person with them in labor are more likely to A. Have epidural anesthesia B. Have a precipitous labor C. Experience fewer birth complications D. Experience more interventions

C. Experience fewer birth complications

A sterile vagina exam reveals that the woman is 5 cm/80%effaced/0station. Based on this exam the woman is A. In the transition phase B. In the latent phase C. In the active phase

C. In the active phase

An involuntary urge to push is most likely a sign of A Malposition of the fetus B. Transition to active labor C. Low fetal station D. Imminent delivery

C. Low fetal station

The primary reason for administering Nubain to a woman in active labor is to A. Slow uterine contractions B. Relieve nausea and vomiting C. Relieve pain D. Promote dilation

C. Relieve pain

False labor is characterized by A. Irregular uterine contractions and cervical change B. Back pain that radiates to the lower abdomen C. The presence of bloody show D. Irregular contractions with no cervical change

D. Irregular contractions with no cervical change

Passenger, as one of the 4 Ps refers to A. position of mother B. Passage of vagina C. fetal descent into pelvis D. The fetus

D. The fetus