evolve Quiz: Pregnancy, Labor, Childbirth, Postpartum - Uncomplicated

A nurse is caring for a client in the first stage of labor and an external fetal heart monitor is in place. What do the tracings indicate?

Variable decelerations are illustrated by a sudden decrease in the fetal heart rate below the baseline, lasting about 15 seconds and then returning to baseline within 2 minutes; they are caused by compression of the umbilical cord. If they occur during the first stage of labor, they usually resolve when the mother is repositioned from one side to the other. Fetal tachycardia is not reflected in this illustration. Early accelerations are transitory and are not evident in this illustration. Inadequate long-term variability is not reflected in this illustration.

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15 seconds. How should the nurse document this event?

An acceleration--An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats/min

Four hours after a vaginal birth, a client still has not voided. What is the next nursing action?

Palpating the client's suprapubic area for distention--> Physical assessment is a part of data collection. It is the first step before the planning of care. Neither planning nor implementation is the initial action.

Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?

ROA, 0 station ---The fetal heart is in the right quadrant; therefore the fetus's head and back are on the right side. The head is engaged and is at 0 station. In left occiput posterior (LOP) position, −2 station, the fetal heart should be heard on the left side; at station −2 the head is mobile. The information states that the head is anterior and flexed; at −3 station the head is mobile. In left occiput anterior (LOA) position, +1 station the fetal heart should be heard on the left side; at +1 station the head is engaged below the ischial spines.

Which position does the nurse teach the client to avoid when she experiences back pain during labor?

Supine--> Low back pain is aggravated when the mother is in the supine position because fetal pressure on the sacral nerves is increased. The Sims position relieves back pain during labor but may not be as comfortable as the other lateral positions. The right lateral position relieves back pain during labor. The left side-lying position relieves back pain during labor.

A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?

Take a walk around the unit with her--Walking may increase the frequency and intensity of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.