EXAM 3 (CH16,17,18,19)

A woman at 37 weeks' gestation calls and reports, "my water broke and I have bloody show. I am changing my pad every ten minutes." Which does the nurse correctly advise the woman to do? Engage in activity such as walking Call her health care provider and go to the hospital or birthing center Advise the woman that overreacting is not good for her or the baby and to call back when she is in "true labor" Remain home, and only come in to the hospital or birthing center if contractions are regular, frequent, and intense

Call her health care provider and go to the hospital or birthing center Heavy bleeding and/or a gush of fluid from the vagina should be evaluated by a health care provider at the hospital or birthing center.

Changes occur as a woman progresses through labor. What maternal adaptations are expected during labor? (Circle all that apply.) A. Increase in both systolic and diastolic blood pressure during uterine contractions B. Decrease in white blood cell count C. Slight increase in baseline pulse and respiratory rates D. Decrease in gastric motility leading to nausea and vomiting, especially during the transition phase. E. Proteinuria 21 F. Hyperglycemia"

Choices A, C, and D are correct; white blood cell count increases; a decrease in blood glucose and proteinuria of 11 can be expected; see Box 16-2." A. Increase in both systolic and diastolic blood pressure during uterine contractions C. Slight increase in baseline pulse and respiratory rates D. Decrease in gastric motility leading to nausea and vomiting, especially during the transition phase.

Internal Fetal Monitoring

In this invasive intervention, the membranes are ruptured and an electrode is attached to the presenting part of the fetus. The mother's cervix must be dilated 2 to 3 cm for internal monitoring to be conducted.

Induction

Induction is the deliberate initiation of uterine contractions that stimulates labor. Elective induction may be accomplished with an infusion of oxytocin (Pitocin). Do not increase rate of oxytocin infusion once the desired contraction pattern (contraction frequency of 2 to 3 minutes and lasting 60 seconds) is obtained. Discontinue oxytocin if contraction frequency is less than 2 minutes, duration is more than 90 seconds, or fetal distress is noted.

Frequency of Contractions- Definition and Measurement

Measured in minutes from the beginning of one contraction to the beginning of the next

Duration of Contractions- Definition and Measurement

Measured in seconds, from the beginning to the end of the contraction

transition

Membranes (the BOW) can rupture spontaneously any time during labor, however, most commonly during the __ phase of the first stage of labor.

Causes of Tachycardia

Hypoxemia, maternal or fetal infection, maternal hyperthyroidism, fetal anemia, response to medications such as methamphetamines or cocaine

While auscultating for fetal heart tones in a pregnant client, the nurse observes that there is persistent fetal tachycardia. In which situation would this finding be considered normal? If the patient's body temperature has increased If the tachycardia is caused by late deceleration If the tachycardia is related to minimal variability If the client's uterine contractions (UCs) are elevated

If the patient's body temperature has increased Rationale Accelerations in the fetal heart rate (FHR) are usually episodic and sometimes they may be persistent. When the patient is febrile, fetal tachycardia is not considered as a serious event. The tachycardia would resolve once the patient is afebrile. Elevation in UCs may cause episodic tachycardia, but not persistent tachycardia. Persistent tachycardia when associated with late deceleration or minimal variability is considered a risk to the fetus.

Which responsibilities should the nurse attend to during a birth? Select all that apply. Prepare a sterile environment. Prepare for perineal cleansing. Educate the father on how to hold child. Educate the mother on latching technique. Prepare for initial assessment of the newborn.

Prepare a sterile environment. This is an appropriate response because the nurse should insure that the birthing area is sterile, including gowns, gloves, drapes. Prepare for perineal cleansing. This is an appropriate response because the nurse should prepare for perineal cleansing during the birth. Prepare for initial assessment of the newborn. This is an appropriate response because the nurse should prepare for the initial assessment of newborn during the birth.

cesarean section preoperative

Preoperative a. If planned, prepare the mother and partner. b. If an emergency, quickly explain the need and procedure to the mother and partner. c. Obtain informed consent. d. Ensure that the preoperative diagnostic tests are done, including Rh factor determination. e. Prepare to insert an intravenous line and a Foley catheter. f. Prepare the abdomen as prescribed. g. Monitor the mother and fetus continuously. h. Provide emotional support. i. Administer preoperative medications as prescribed.

Strength of Contractions

Uterine contractions range from peaking at 40-70 mm Hg in first stage of labor to more than 80 mm Hg in second stage.

What is the best location to palpate contractions during the assessment of the laboring patient? Vagina Lower back Cervical canal Uterine fundus

Uterine fundus The best location to palpate contractions is at the uterine fundus.

stress

The father, coach, or significant other also experiences __ during labor. It is important to be sensitive to the needs of support persons and provide teaching and support as necessary.

Resting Tone measurement

Tone of uterus between contractions; described as soft or hard

cleansing breath

a slow deep breath that is taken at the beginning and end of each contraction of labor

anesthesia

abolition of pain perception by interrupting nerve impulses to the brain. loss of sensation (partial or complete) and sometimes loss of consciousness occurs.

false pelvis

above pelvic brim no part in childbearing

expulsion

after birth of shoulders, the trunk of the baby is born by flexing it laterally in the direction of symphesis pubis baby emerges, birth complete, 2nd stage ends

lessen degree of laceration

application of warm compress gentle perineal massage

Ritgen manuever

apply upward pressure from the coccygeal region to extend the head during the actual birth, thereby protecting the musculature of the perineum

3 main presentations

cephalic, breech, shoulder

regional anesthesia

complete pain relief and motor block

stadol adverse effects

confusion sedation hallucinations floating feeling drowziness respiratory depression nausea and vomiting transient nonpathological sinusoidal-like fetal heart rate pattern

bloody show

brownish or blood tinged cervical mucus

Focusing and relaxation techniques

reduce tension adn stress, allow conserve energy attention focusing - bring a favourite object to labor room and focus attention on this onject during contractions imagery - focuses attention on pleasant scene relaxation - drinking herbal tea ( also fluid maintains), quite relaxed environment

woman after C section

restricted to clear liquids and ice chips

maternal adaptation to labor/ integumentary

stretching tissue ( vaginal introitus) episiotomy, lacerations

soft tissues

stretchy lower uterine segment cervix pelvic floor muscles vagina introitus

meperidine adverse effects

tachycardia sedation nausea and vomiting dizziness altered mental status euphoria decreased gastric motility delayed gastric emptying urinary retention

Placenta affect on birth

none except placenta previa

timing of pharmacological administration

nurse contacts MD based on clinical judgement systemic opioids not until labor is established

Referred pain

occurs when the pain originates in the uterus and radiates to the lower abdominal wall, lumbosacral area, back, iliac crest, gluteal area, thighs, and lower back. Some may always have pain in their backs.

vaginal laceration

often occur in conjunction with perineal lacerations; tend to extend up the lateral walls (sulci) and if deep enough, involve the levator ani muscle

nulliparous women sensory labor pain during early labor

greater than multiparous due to less flexible tissues

maternal adaptations to labor/ MS

diaphoresis, fatigue, protenuria 1+, increased temperature - increased muscle activity backache, joint ache - due to increased joint laxity at term leg cramps

Modified paced breathing

performed at about twice the normal breathing rate -IN-OUT/IN-OUT/IN-OUT... for more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginners and ends of contractions and modified breathing for more intense peaks

tachycardia

persistent (10 minutes or longer) baseline FHR greateer than 160 beats/min

external forces affecting birth

place of birth preparation type of provider procedures

Schultze mechanism

placenta first appears by its shiny fetal surface

pain threshhold

point beyond which pain is perceived

hypoxia

inadequate supply of oxygen at the cellular level

uterine contractions

indepenent of external forces paralyzed women have painless contractions epidural doesnt effect

local perineal infiltration anesthesia

provides rapid perineal anesthesia for performing and repairing an episiotomy or lacerations

hyperventilation

rapid, deep breathing that can be an undesirable outcome of the more rapid and more shallow types of paced breathing techniques; it can result in respiratory alkalosis

intradermal water block

injection of small amounts of sterile water using a fine needle into four locations on the lower back to relieve low back pain

Somatic Pain

intense, sharp, burning, and well localized pain during the second stage of labor.

uniqueness of pain

intensity of discomfort is unique to all

Intrauterine pressure catheter

interanl monitoring instrument that is solid or fluid filled; it is inserted into the intrauterine cavity to measure uterine activity

Spiral electrode

internal monitoring instrument that is attached to the fetal presenting part to assess FHR pattern

general anesthesia difficulties/nursing considerations

intubation aspiration NPO IV infusion in place premedicre with antacids or H2 to block production of acid preoxygenate with 100% by nonrebreather for 2-3 min deliver baby asap to avoid fetal narcosis and resuce the risk of hemorrhage

What is Uterine ischemia and when does it occur?

is decreased blood flow and therefore local oxygen deficit) results form compression of the arteries supplying the myometrium during uterine contractions.

duration of contractions

length contraction

pain tolerance

level of pain a laboring woman is willing to endure

oblique

long axis of the fetus is lying at an angle to the long axis of the mother less common usually converts to a longitudinal

vertical lie/ longitudinal

long axis of the fetus is parallel with the long axis of the mother 99% of term labor

primary lies

longitudinal vertical

Hypotension - Emergency

marked hypotension, impaired placental perfusion, and an ineffective breathing pattern may occur during spinal anesthesia

After induction of anesthesia

maternal vital signs every 5-10 min., along with FHT. Considered hypotension if below 100 mm/hg or 205 reduction of the baseline

Fetal pulse oximetry

method of assessment that monitors fetal oxygen saturation levels

maternal adaptations to labor/ GI

motility and absorption of solid foods decreased stomach emptying time slows nausea, vomiting of undigested food during onset of labor, belching as reflex response to full cervical dilation diarrhea during onset of labor may have hard impacted stool in the rectum

labor

moving the fetus, placenta, and membranes out of the uterus and through the birth canal

nulliparous women during transition pahse and early 2nd stage

multiparous have greater pain due to flexiblae tissues and speed of fetal descend

side effects of epidural

nausea vomiting diminishing peristalsis pruritus urinary retention delayed respiratory depression use antiemetics, antipruritics and opioid antagonist for releif (naloxone, metalclopromide)

In a variation of rooming-in, called couplet care, the mother and infant share a room and the mother shares the care of the infant with whom? The father of the infant Her mother (the infant's grandmother) Her eldest daughter (the infant's sister) The nurse

the nurse Rationale In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room-maternity-care. The father is included in instruction regarding infant care whenever he is present. The grandmother is welcome to stay and take part in the woman's postpartum care, but she is not part of the couplet. An elder sibling may stay with the client and her baby but is not part of the couplet.

presentation

the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor

presenting part

the part of the fetus that lies closest to the internal os of the cervix it is the part of the body that is felt first by the examiner's finger during a vaginal examination

type and screen

the patient's blood type and Rh factor are determined, and a general antibody screen is performed on admission

pain threshold

the point at which a person feels pain similar for all regardless of age, gender, culture etc

Passenger Movement Elements

the size of the fetal head fetal presentation fetal lie fetal attitude fetal position

Gate control

theory of pain based on the principle that certain nerve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. According to this theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations or messages can travel through these nerve pathways at one time

effacement

thinning and shortening of the cervix during first stage

not admitted

till dialated 3 cm

nuchal cord

umbilical cord encircling the neck of the baby

mediolateral episiotomy

used in operative births when the need for posterior extension is likely

transverse

vaginal labor cannot occur

vertex

when the presenting part is the occiput

breastfeeding initiated

within 1 hr after birth

The nurse instructor is teaching a group of students about the structure of the fetal head during labor and birth. Which statement by the student indicates effective learning? "The fetal skull bones are firmly united during labor." "The fetal skull bones are united by membranous sutures." "The two important fontanels are the parietal and temporal." "The sutures and fontanels restrict brain growth after delivery."

"The fetal skull bones are united by membranous sutures." Rationale Membranous sutures, including sagittal, lambdoidal, coronal, and frontal, unite the fetal skull bones. The fetal skull bones are flexible at birth and a slight overlapping of the bones may occur during labor. The two important fontanels are the anterior and posterior. The sutures and fontanels do not close at birth but instead allow flexibility to accommodate the brain, which continues to grow after birth.

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3. Since this woman is a multipara, the position is LOA and the station is 3, this is an accurate statement.

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

2. These are signs of placental delivery.

A client, who is 7 cm dilated and 100% effaced, is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers with some lightheadedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

2. This comment is consistent with a woman in the transition phase of stage 1.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must precede this assessment? 1. Place the client in the lateral recumbent position. 2. carefully analyze the baseline data on the monitor tracing 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2. carefully analyze the baseline data on the monitor tracing

Between contractions, a client in the active phase of labor states, "not only do thesecontractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting too". The patient request medications to reduce her pain. It would be the most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-reliving methods? 1. epidural 2. nitrous oxide 3. narcotic analgesic 4. spinal

2. nitrous oxide

Stage 4

1. Description: Period 1 to 4 hours after delivery 2. Assessment a. Blood pressure returns to prelabor level. b. Pulse is slightly lower than during labor. c. Fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus. 3. Interventions a. Perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 2 hours (or as per agency policy). b. Provide warm blankets. c. Apply ice packs to the perineum. d. Massage the uterus if needed, and teach the mother to massage the uterus. e. Provide breast-feeding support as needed.

basic types of pelves

1. gynecoid (classic female) 2. android (resembling the male pelvis) 3. anthropoid ( oval shaped, with a wider anteroposterior diameter) 4. platypelloid (flat pelvis)

labor support by the nurses

1. helping maintain control and participate to the extent she wishes 2. providing continuity of care that is nonjudgemental and respectful of her cultural and religious values and beliefs 3. meeting her expected outcomes for her labor 4. listening to her concerns and encouraging her to express her feelings 5. acting as her advocate, supporting her decisions 6. helping her conserve her energy and cope effectively with pain 7. helping control her discomfort 8. acknowledging her efforts during labor 9. protecting her pravacy

factors influencing laboring woman pain tolerance

1. her desire for natural, vaginal birth 2. her preparation for childbirth 3. her level of anxiety 4. the nature of her support during labor 5. her willingness and ability to participate in nonpharmacological measures for comfort

women's satisfaction with her labor determined

1. how well her personal expectations of childbirth were met 2. quality of support and interactions she received from her caregivers 3. she was able to stay in control of her labor 4. to participate in decision making process ( including pahm and non pahrm pain relief)

4 Leopold maneuvers

1. identifying the fetal part in the uterine fundus to determine fetal lie and presenting part 2. palpating the fetal back to identify fetal presentation 3. Determining which fetal part lies over the pelvic inlet to identify fetal attitude 4. Locating the fetal cephalic prominence to identify the attitude of the head

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? 1. lengthening of the umbelical cord 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

1. lengthening of the umbelical cord 3. Uterus rising in the abdomen and feeling globular.

major priorities newborn's immediate care

1. maintaining patent airway supporting respiratory effort preventing cold stress by drying and covering with a warmer blanket ( on mother chest or under radiant light)

in response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide in NO2 50% /O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? SATA 1. Nausea 2. Hypotension 3. Dehydration 4. Light-headedness 5. Late fetal heart descelerations

1. nausea 4. light-headedness

risk factors of perineal trauma

1. nulliparous light skinned reddish hair maternal nutritional status birth position pelvic anatomy fetal malpresentation and position large infants use of forceps or vacuum prolonged second stage rapid labor

Factors influencing pain response

1. physiological factors 2. culture 3. anxiety 4. previous experience 5. gate control theory of pain 6. comfort 7. environment

descend depends of 4 forces

1. pressure exerted by the amniotic fluid 2. direct pressure exerted by the contracting fundus on the fetus 3. force of the contractionof the maternal diaphragm and abdominal muscles in the second stage of labor 4. extension and streightening of the fetal body they are modified by size and shape of pelvis and size of head

suggested measures for supporting a woman in labor

1. provide companionship and reassurance 2. offer positive reinforcement and praise for her efforts 3. encourage participating in distracting activities and nonpharmacological measures 4. give nourishment if allowed 5. assist with personal hygiene 6. offer information and advice 7. involve the woman in decision making regarding her care 8. interpret the woman's wishes to other health care providers and to her support group 9. create a relaxing environment 10. use calm and confident approach 11. support and encourage the woman's support people by role modeling labor support measures and providing time for breaks

A woman, G2 P0101, 5 cm dilated and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following in terventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Assist the woman in changing position. 4. Urge the woman to perform the next level breathing.

4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4. When the baby's chin is on his or her chest, the baby is in the flexed attitude.

intrauterine pressure catheter (IUPC)

A catheter that can be placed through the cervix into the uterus to measure uterine pressure during labor. Most accurate way of assessing the intensity of uterine contractions and uterine resting tone.

How might a pubic arch of 85 degrees affect labor? A pubic arch of 85 degrees allows for adequate dilatation and effacement. A pubic arch with an angle less than 90 degrees is ideal for the fetus to pass under it. A pubic arch with an angle less than 90 degrees may impede the fetus from passing under it. A pubic arch of 85 degrees prevents the uterus from producing coordinated, effective contractions

A pubic arch with an angle less than 90 degrees may impede the fetus from passing under it. The angle of the pubic arch should be at least 90 degrees. A narrow pubic arch displaces the fetus posteriorly toward the coccyx as it tries to pass under the arch.

The nurse is assessing uterine activity and understands that which finding regarding uterine relaxation between contractions is reassuring? A relaxation of 5 seconds between contractions No relaxation between contractions A relaxation of 40 seconds between contractions A relaxation of 10 seconds between contractions

A relaxation of 40 seconds between contractions The uterus should relax for at least 30 seconds between contractions to allow optimal uteroplacental exchange.

Nurses can advise their clients that which of these signs precede labor? Select all that apply. A return of urinary frequency as a result of increased bladder pressure Persistent low backache from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions A decline in energy, as the body stores up for labor Uterus sinks downward and forward in first-time pregnancies.

A return of urinary frequency as a result of increased bladder pressure Persistent low backache from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions Uterus sinks downward and forward in first-time pregnancies.

Psyche

A woman's emotional structure that can determine her entire response to labor and influence physiological and psychological functioning; Mother may experience anxiety or fear

Which pregnant woman would be advised to go to the hospital? Select all that apply. A pregnant woman with a decrease in the fetal kick count by half A multipara with regular contractions every 5 minutes for 2 hours A pregnant woman who experiences heavy, bright red bleeding A pregnant woman who reports a pink-tinged mucus discharge A primigravida with regular contractions every 15 minutes for 5 hours

A pregnant woman with a decrease in the fetal kick count by half Decreased kick count suggests decreased fetal movement and may be a medical emergency. A multipara with regular contractions every 5 minutes for 2 hours The multipara should report to the hospital if experiencing regular contractions at least 10 minutes apart, for at least 1 hour. A pregnant woman who experiences heavy, bright red bleeding Bleeding that is bright red and not mixed with mucus must be evaluated immediately.

Episiotomy Care

Check episiotomy site. Institute measures to relieve pain. Provide ice pack for the 24 hours after procedure. Instruct the client in the use of sitz baths (immersion of the perineal or episiotomy area in the warm water solution). Apply analgesic spray or ointment as prescribed. Provide perineal care, using clean technique; apply a peripad without touching the inside surface of the pad. Instruct the client in proper care of incision. Instruct the client to dry perineal area from front to back and to blot area instead of wiping it. Instruct the client to shower rather than bathe in a tub to decrease the risk of infection at the episiotomy site. Report any bleeding or discharge to the physician.

Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetric patient who is in early labor? Select all that apply. Biparietal diameter of less than 9.25 cm Vertex presenting part Transverse lie General flexion attitude Android pelvi

Biparietal diameter of less than 9.25 cm A biparietal diameter at term is typically noted as 9.25 cm, and the finding of a smaller measurement would cause a concern related to the mode of delivery. A transverse lie would also cause a concern relative to the mode of delivery because a cesarean section would be indicated. An android pelvis would cause a concern related to the mode of delivery. A vertex presenting part and a general flexion attitude are normal findings and would not cause concern. Transverse lie Android pelvis

The nurse is helping a pregnant client during labor by applying fundal pressure. What alteration in the fetal heart rate pattern will result from this intervention? Early decelerations Late decelerations Variable decelerations Prolonged decelerations

Early decelerations Rationale Applying fundal pressure can cause fetal head compression and it may cause early decelerations in FHR. Disruption of oxygen transfer from the maternal environment to the fetus may result in late decelerations. Variable decelerations may be observed due to umbilical cord compression. If the mechanisms responsible for late or variable decelerations last for extended period, then they cause prolonged decelerations.

Which of the following FHR tracing characteristics are considered reassuring or normal (category I)? Bradycardia not accompanied by baseline variability Early decelerations, either present or absent Sinusoidal pattern Tachycardia

Early decelerations, either present or absent Rationale Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing. Fetal tachycardia is a category II tracing and not considered normal.

A group of fetal monitoring experts (National Institute of Child Health and Human Development, 2008) recommends that fetal heart rate (FHR) tracings demonstrate certain characteristics to be described as reassuring or normal (category I). These characteristics include: Bradycardia not accompanied by baseline variability. Early decelerations, either present or absent. Sinusoidal pattern. Tachycardia.

Early decelerations, either present or absent. Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing, as is fetal tachycardia. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing.

A client is in active labor, with her cervix dilated to approximately 5 cm. She is beginning to tire and express discouragement. What can the nurse initiate to provide comfort and help reduce the risk of prolonged labor? Biofeedback Hydrotherapy Spinal anesthesia Intradermal water block

Hydrotherapy Rationale An active labor with dilation of approximately 5 cm will increase contractions and pain and tire the client, so hydrotherapy is initiated to provide pain relief and relaxation. Biofeedback may be helpful initially but the client may need pain medication if the pain increases. The primary health care provider may order spinal anesthesia in case the client has a cesarean birth. An intradermal water block is used to relieve lower back pain during labor.

combined spinal epidural (CSE) analgesia

In the _____ technique, sometimes refered to as a walking epidural, an epidural needle is inserted into the epidural space. Before the epidural catheter is placed, a smaller-gauge spinal needle is inserted through the bore of the epidural needle into the _______. A small amount of opioid or combination of opioid and local anesthetic is then injected intrathecally to rapidly provide analgesia. Afterward the epidural catheter is inserted as usual. Although women can walk (hence the term walking epidural), they often choose not to do so because of ______ and _____, abnormal sensations in and weakness of the legs, and a feeling of insecurity.

Signs of potential complications during labor:

Intrauterine pressure >80mmHg or resting tone of >20mmHg Contractions >90 sec More than 5 contractions in 10 min Relaxation between contractions <30 sec Fetal brady/tachycardia; absent or minimal variability not associated with fetal sleep cycle or temporary effects of CNS depressant drugs given to the woman; late, variable, or prolonged FHR decelerations Irregular FHR Meconium-stained or bloody fluid from vagina Arrest in progress of dilation, effacement, descent or all 3 Maternal temperature >38C (100.4F) Foul smelling vaginal discharge Persistent bright or dark red vaginal bleeding

Which device should the nurse use for monitoring the intensity of uterine contractions (UCs) in a pregnant client? Tocotransducer Spiral electrode Ultrasound transducer Intrauterine pressure catheter (IUPC)

Intrauterine pressure catheter (IUPC) Rationale An IUPC measures the frequency, duration, and intensity of contractions during the intrapartum period. The device records the pressure at the catheter tip, and the values are expressed in terms of mm Hg. However, for accurate readings the membranes should be ruptured and the cervix should be dilated. A tocotransducer monitors the frequency and duration of contractions for both antepartum and intrapartum care. This device is placed on the abdomen of the client. Spiral electrodes and ultrasound transducers are used for assessing the fetal heart rate, not the intensity of contractions. A spiral electrode is an invasive mode, whereas an ultrasound transducer is a noninvasive mode.

Intermittent Auscultation (IA)

Involves listening to fetal heart sounds at periodic intervals to assess the FHR -can be done with a Pinard fetoscope, doppler ultrasound, an ultrasound stethoscope, or a DeLee-Hillis fetoscope -allows woman more freedom of movement than EFM - difficult to use in obese women -cannot be used to assess visual patterns of the FHR variability or periodic changes -Less likely to overtreat (C-section, fetal scalp blood sample) inexpensive hard to perform on obese doesn't provide a permanent document visual record of the FHR

A client has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail? Select all that apply. It is a crucial time for mother and newborn. The fourth stage of labor is delivery of the fetus. The fourth stage of labor includes delivery of the placenta. The fourth stage of labor includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members.

It is a crucial time for mother and newborn. The fourth stage of labor includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members. Rationale The fourth stage of labor is a crucial time for the mother and the newborn; it includes the first 1 to 2 hours after birth. During this time maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but are also becoming acquainted with each other and additional family members. The second (not fourth) stage of labor is delivery of the fetus. The third (not fourth) stage of labor includes delivery of the placenta.

Which statement is inaccurate with regard to normal labor? A single fetus presents by vertex. It is completed within 8 hours. A regular progression of contractions, effacement, dilation, and descent occurs. No complications are involved.

It is completed within 8 hours. Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours. In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor, which usually occurs with no complications.

A multiparous patient has been laboring for 2 hours. On her last vaginal examination, the nurse found the patient's cervix to be dilated 6 cm and 90% effaced with the fetal head presenting at +1 station. The patient refused IV pain medication as well as an epidural anesthetic, stating, "I did it without anything with my other baby." Now the patient reports an occasional urge to push and requests pain medication in her IV line. With the next contraction, the patient cries out, "I feel like I need to have a bowel movement." What should the nurse do at this time? Call the practitioner and request pain medication for the patient. Check the perineum and perform a sterile vaginal examination. Instruct the patient's support person on providing comfort measures. Encourage the patient to ambulate in the room.

Check the perineum and perform a sterile vaginal examination

A primigravida calls the hospital and tells a nurse on the labor unit that she knows she is in labor. The nurse's initial response is: A. "Tell me why you know that you are in labor." B. "How far do you live from the hospital?" C. "When is your expected date of birth?" D. "Have your membranes ruptured?""

Choice A is correct; although choices B, C, and D are all important questions, the first question should gather information regarding whether or not the woman is in labor." A. "Tell me why you know that you are in labor."

What will the nurse mention about the effect of secondary powers during labor to the client? Contractions are expulsive in nature. The intraabdominal pressure is decreased. Contractions move downward in waves. Contractions begin at pacemaker points.

Contractions are expulsive in nature. Rationale As soon as the presenting part of the fetus touches the pelvic floor, the client uses secondary powers or bearing-down efforts. This results in contractions that are expulsive in nature. The voluntary bearing-down efforts of the client also result in increased intraabdominal pressure. Primary powers signal beginning of labor with involuntary contractions that move downward over the uterus in waves. These contractions begin at pacemaker points in the thickened muscle layers of the upper uterine segment.

Which test is performed to determine whether membranes are ruptured? Urine analysis Fern test Leopold maneuvers AROM

Fern test In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery to determine the presence or absence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

While monitoring the fetal heart rate (FHR) of a client, the nurse notes a regular, smooth, undulating wavelike pattern. Which condition does the nurse suspect when observing this pattern? Prematurity Tachycardia Fetal anemia Neurologic injury

Fetal anemia Rationale A sinusoidal pattern is a regular, smooth, undulating wavelike pattern. This pattern classically occurs with severe fetal anemia. Minimal variability in the FHR may indicate prematurity or tachycardia. Absent variability may indicate preexisting neurologic injury or congenital anomalies.

Following assessment of an actively laboring woman, the nurse finds a fetal heart rate (FHR) of 180 beats per minute with contractions occurring less than two minutes apart and lasting more than 90 seconds. Incomplete relaxation of the uterus is also observed by the nurse. Which is indicated by these findings? Fetal compromise Fetal oxygenation Increased maternal anxiety Increased maternal discomfort

Fetal compromise If any of the listed signs are identified, assess the fetus more frequently and notify the birth attendant as fetal compromise is indicated.

The nurse is caring for a patient in the second stage of labor. The patient reports burning pain across her perineum. The nurse understands that this is likely related to which cause? Fetal descent Cervical dilation Uterine contractions Cervical effacement

Fetal descent Burning pain across the perineum in the second stage of labor is likely due to fetal descent. This occurs along with marked distension of the vagina and perineum. The patient may report a sensation of burning, tearing, or splitting.

Which noninvasive tools may be used to evaluate the fetal heart rate? Select all that apply. Fetoscope Uterine palpation Doppler ultrasound Fetal scalp electrode Intrauterine pressure catheter (IUPC)

Fetoscope The fetoscope is one example of a noninvasive monitoring device to evaluate the fetal heart rate. It allows the nurse to listen to the opening and closing of the valves. Doppler ultrasound The Doppler ultrasound is a noninvasive tool used to evaluate the fetal heart rate. Doppler can make the fetal heart audible and automatically count the heart rate.

The primary health care provider prescribes terbutaline (Brethine) for a pregnant client. As the nurse reviews the client's medical record, what would be the rationale for this prescription? Blood volume is elevated. Hemoglobin is decreased. Blood pressure is reduced. Contractions are increased.

Contractions are increased. Rationale Terbutaline (Brethine) is administered to the client who has premature labor. It slows down the contractions. Terbutaline (Brethine) has no effect on blood volume, blood pressure, and hemoglobin. Blood volume is elevated by infusing aggressive intravenous infusion or from sodium and water retention. Maternal hypotension, as evidenced by reduced blood pressure, is relieved by elevating the legs during labor. Clients with decreased hemoglobin are treated with iron supplements, not terbutaline (Brethine).

Which assessment finding is common for the patient in the latent phase of labor? Contractions are strong and every 1.5-2 minutes Contractions are strong lasting longer than 120 seconds Contractions are moderate and 2-3 minutes apart Contractions are mild to moderate and 10-30 minutes apart

Contractions are mild to moderate and 10-30 minutes apart Contractions 10 to 30 minutes apart are typical for the latent phase.

True labor

Contractions increase in duration and intensity Cervical dilation and effacement are progressive Fetus becomes engaged in pelvis and begins to descend

Variability

Fluctuations in baseline FHR -Absent or undetected is nonreassuring -Decreased can result from fetal hypoxemia, acidosis or meds -Temporary decrease can occur when fetus is in a sleep state (not longer than 30 min)

Which of the following would not be included in a labor nurse's plan of care for an expectant mother? The onset of progressive, regular contractions The bloody, or pink, show The spontaneous rupture of membranes Formulation of the woman's plan of care for labor

Formulation of the woman's plan of care for labor Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment.

Which part of the labor contraction cycle is the nurse describing when stating, "Contractions are 2.5 to 3 minutes apart"? Peak Increment Decrement Frequency

Frequency Frequency is the period from the beginning of one uterine contraction to the beginning of the next; it is usually expressed in minutes and fractions of minutes.

The nurse assisting a laboring client recognizes the Ferguson reflex in the patient. What is the Ferguson reflex? Release of endogenous oxytocin Involuntary uterine contractions Maternal urge to bear down Mechanical stretching of the cervix

Maternal urge to bear down Rationale The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex is occurs when stretch receptors in the posterior vagina cause release of endogenous oxytocin. The involuntary uterine contractions or primary powers originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. Intrauterine pressure caused by contractions exerts pressure on the descending fetus and the cervix. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs.

Station

Measurement of the progress of descent in cm above or below the midplane from the presenting part to ischial spine Station 0= at ischial spine Minus station= above ischial spine Plus station= below ischial spine Engagement= widest diameter of presenting part has passed the inlet, corresponds to a 0 station

Intrathecal opioid analgesics

Medication is injected into subarachnoid space and has a rapid onset of action. Used in combination with a lumbar epidural block

What physiologic change can the nurse expect to see in the client during labor pain? Reduced heart rate Respiratory acidosis Pallor and diaphoresis Reduced blood pressure

Pallor and diaphoresis Rationale Pallor and diaphoresis is commonly observed in clients during labor pain. Blood pressure tends to increase during labor. The client consumes more oxygen, leading to hyperventilation accompanied by respiratory alkalosis. The nurse must teach the client to perform rapid shallow breathing techniques during contractions. Intensifying pain may increase maternal heart rate during labor.

Identify the four steps in the order in which they will be used to perform the Leopold's Maneuver.

Palpate the uterine fundus. Palpate for the fetal back. Palpate the suprapubic area to confirm presentation. Determine if head is flexed (vertex) or extended (face). The purpose for performing the Leopold's Maneuver is to find the fetal back, which is the best place to auscultate the FHR. The nurse first palpates the uterine fundus, then for the fetal back. Finally, the nurse palpates the suprapubic area to confirm presentation. The nurse would then determine if the head is flexed or extended.

What are the causes of somatic pain in a client who is in the second phase of labor? Select all that apply. Pressure against the bladder Distention of the peritoneum Stretching of the perineal tissue Involuntary uterine contractions Decreased blood flow to the uterus

Pressure against the bladder Distention of the peritoneum Stretching of the perineal tissue Rationale Somatic pain is a result of distention and traction of the peritoneum, stretching of the perineal tissue, and pressure against the bladder and rectum. This pain is intense, sharp, burning, and well-localized in the second stage of labor. Uterine ischemia, or decreased blood flow to the uterus, causes visceral pain in the first stage of labor. Involuntary uterine contractions leading to cervical dilation and effacement also lead to pain in the first stage of labor.

What does the nurse teach a group of expectant mothers about slow-paced breathing? It is performed at half the normal breathing rate. It is initiated at the onset of the first stage of labor. It is beneficial if performed with full concentration. It is repeated at the onset of the second stage of labor.

It is performed at half the normal breathing rate. Rationale Slow-paced breathing is performed at approximately half the patient's normal breathing rate. It is initiated in the first stage of labor when the patient can no longer walk or talk through contractions. Patterned-pace breathing, not slow-paced breathing, is performed during the onset of the second stage of labor. Modified-paced breathing requires the patient to remain alert and concentrate more fully on breathing.

The nurse is caring for a client with electronic fetal monitoring using a spiral electrode. How is the use of a spiral electrode different from the use of an ultrasound transducer? It is used only during the antepartum period. It is used when the cervix has not yet dilated. It is applied firmly to the maternal abdomen. It is used after the membranes have ruptured.

It is used after the membranes have ruptured. Rationale A spiral electrode can be used only after the membranes have ruptured. The electrode is attached securely to the presenting fetal body part to obtain a good signal. It can be used only during the intrapartum period and only if the cervix is sufficiently dilated and the membranes are ruptured. A tocotransducer is applied firmly to the maternal abdomen to monitor the frequency and duration of contractions. A spiral electrode penetrates into the presenting part by 1.5 mm.

During the prenatal assessment of a client, the nurse teaches the client about nonpharmacologic pain management. What does the nurse tell the client about this method? It is technical and expensive. It requires intensive training. It provides the patient with a sense of control. It is used only in stage I of labor.

It provides the patient with a sense of control. Rationale The client makes choices about the nonpharmacologic pain management methods that are best suited. This provides the client with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the client may obtain best results from the practice. It can be used throughout labor.

Major Shortcoming of EFM

Its high rate of false-positive results -most abnormal patterns are poorly predictive of neonatal morbidity

Stage 1 Interventions

Keep mother and partner informed of progress. Provide privacy. Offer fluids and ice chips, plus ointment for dry lips. Encourage voiding every 1 to 2 hours. Monitor maternal vital signs. Monitor FHR with the use of a Doppler ultrasound transducer, fetoscope, or electronic fetal monitor. Assess FHR before, during, and after a contraction, keeping in mind that the normal FHR is 120 to 160 beats/min. Assess uterine contractions by means of palpation or monitor, determining frequency, duration, and intensity. Assess status of cervical dilation and effacement. Assess fetal station presentation and position, using the Leopold maneuvers. Assist with pelvic examination and prepare for a Nitrazine test and a fern test as prescribed. Assess the color of the amniotic fluid if the membranes have ruptured (check the FHR immediately after rupture); meconium-stained fluid may indicate fetal distress.

A laboring patient reports moderate back pain. Her partner rubs her lower back and reminds her to look at the teddy bear they bought for the newborn. This is an example of which relaxation technique(s)? Select all that apply. Massage Focal point Hydrotherapy Acupressure Mental imagery

Massage Massage is a form of cutaneous stimulation that involves rubbing areas of pain to reduce discomfort. This relaxation technique can help with lower back pain during labor. Correct Focal point The use of a teddy bear to look at during labor is an example of a focal point. By using a focal point, the woman focuses on an external focal point usually on object with positive associations) as opposed to the internal sensation of pain.

What are the causes of somatic pain in a client who is in the second phase of labor? Select all that apply. Pressure against the bladder Distention of the peritoneum Stretching of the perineal tissue Involuntary uterine contractions Decreased blood flow to the uterus

Pressure against the bladder Distention of the peritoneum Stretching of the perineal tissue Rationale Somatic pain is a result of distention and traction of the peritoneum, stretching of the perineal tissue, and pressure against the bladder and rectum. This pain is intense, sharp, burning, and well-localized in the second stage of labor. Uterine ischemia, or decreased blood flow to the uterus, causes visceral pain in the first stage of labor. Involuntary uterine contractions leading to cervical dilation and effacement also lead to pain in the first stage of labor.

During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

The order of change during the third stage of labor is: 3, 4, 1, 2 3. The contraction of the uterus after deliv ery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uter ine wall after the placenta separates and begins to be born.

Visceral pain

The pain from distension of the lower uterine segment, stretching of cervical tissue as it effaces and dilates and , pressure and traction on adjacent structures (e.g. uterine tubes, ovaries, ligaments) and nerves, and uterine ischemia during the first stage of labor, causing a lack of oxygen located over the lower portion of the abdomen

The nurse assesses a fetus as being in the cephalic presentation. What does the nurse mean by the term "fetal presentation?" The relation of the presenting part to the mother's pelvis The relation of the fetus's and mother's spine The part of the fetus that enters the pelvic inlet first The relation of the fetal body parts to one another

The part of the fetus that enters the pelvic inlet first Rationale Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero.

Attitude

The relationship of the fetal body parts to one another Normal intrauterine attitude is flexion (fetal back is rounded, head is forward on the chest, arms and legs are folded in against the body.) Extension tends to present larger fetal diameters

Fetal well-being during labor is assessed by monitoring what? The response of the fetal heart rate (FHR) to uterine contractions (UCs) Maternal pain control Accelerations in the FHR An FHR greater than 110 beats/minute

The response of the fetal heart rate (FHR) to uterine contractions (UCs) Rationale Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/minute with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/minute may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

Fetal well-being during labor is assessed by: The response of the fetal heart rate (FHR) to uterine contractions (UCs). Maternal pain control. Accelerations in the FHR. An FHR greater than 110 beats/min

The response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Although FHR accelerations and an FHR greater than 110 beats/min may be reassuring, they are only two components of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

What happens during the second stage of labor? The second stage of labor is the stage in which the infant is born. In this stage, the birthing table is usually set up for the nulliparous woman. The progress of labor is enhanced when a woman changes her position frequently during this stage of labor. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of this stage of labor is 50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous women.

The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of this stage of labor is 50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous women. Rationale During the second stage of labor the infant is born; this stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of second-stage labor is 50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous women. In the first stage of labor, the birthing table is usually not set up for the nulliparous woman, and the progress of labor is enhanced when a woman changes her position frequently.

The nurse notes variable fetal heart rate (FHR) decelerations while monitoring the fetal heart rate of a patient. What causes variable decelerations? Uterine tachysystole Maternal hypertension Umbilical cord compression Epidural or spinal anesthesia

Umbilical cord compression Rationale Variable FHR decelerations are usually transient and correctable. They can occur at any time during the uterine contraction phase and are caused by umbilical cord compression. Uterine tachysystole is a condition that causes frequent uterine contractions, often more than five contractions in 10 minutes. This causes disruption of oxygen transfer from the environment to the fetus, leading to late decelerations. Maternal hypertension leads to late FHR decelerations due to reduced oxygen transfer to the fetus. Epidural or spinal anesthesia reduces blood flow through maternal vessels, causing late decelerations.

While assessing a pregnant client who is in labor, the nurse observes W-shaped waves on the fetal heart rate monitor. What would the nurse infer from this observation? Placental abruption Dilated cervical layers Umbilical cord compression Elevated uterine contractions

Umbilical cord compression Rationale W-shaped waves in the FHR monitor are indicative of variable decelerations in the FHR. Variable decelerations are seen when the umbilical cord is compressed at the time of labor. Placental abruption and dilated cervical layers do not cause variable decelerations, but may cause late decelerations. Similarly, increased rate of UCs may also cause late decelerations in FHR.

The nurse is monitoring the fetal status of a client in labor. What are the causes that can lead to a decrease in fetal oxygen supply? Select all that apply. Maternal obesity Umbilical cord prolapse Supine maternal position Increase in blood volume Excessive exogenous oxytocin

Umbilical cord prolapse Supine maternal position Excessive exogenous oxytocin Rationale If the umbilical cord prolapses, it can decrease the amount of oxygenated blood to the fetus. A supine maternal position can lead to hypotension, which reduces the blood flow through the maternal vessels and in turn decreases the fetal oxygen supply. Excessive exogenous oxytocin production can lead to uterine hypertonus. This reduces the blood flow to the intervillous space in the placenta. Maternal obesity does not decrease fetal blood flow. Hemorrhage or anemia leading to decrease in blood volume can cause a decrease in the fetal oxygen supply. An increase in blood volume would increase oxygen levels.

The nurse has administered lorazepam (Ativan) along with opioids to a client to relieve labor pain. Which sign in the client indicates a need for metoclopramide (Reglan)? Central nervous system (CNS) depression Nausea and vomiting Unrelieved pain Decreased uterine contractions

Unrelieved pain Rationale Metoclopramide (Reglan) is an antiemetic, which may potentiate the effect of the analgesic. Naloxone (Narcan) is an opioid antagonist that helps relieve central nervous system (CNS) depression in a client. Lorazepam (Ativan) reduces nausea and vomiting in the client when administered along with an opioid. Opioids inhibit uterine contractions, so they are not administered until labor is well established.

pelvic inlet

Upper border of the true pelvis. formed - anteriorly by upper margins of the pubic bone; - - laterally by the iliopectineal lines - posteriorly by the anterior upper margin of the sacrum and the sacral promontory

Anhydramnios

absence of amniotic fluid

flexibility of sutures and fontanels

accomodate growing brain molding of the shape sliding over one another - adaptation to the various diameters of the maternal pelvis

contraindications to subarachnoid and epidural blocks

active or anticipated serious maternal hemorrhage maternal hypotension coagulopathy like anticoagulants meds infection at the injection site increased intracranial pressure allergy to drug maternal refusal

Post anesthesia recovery( PAR) components

activity respirations blood pressure level of consciousness color

to pass the tube

administer muscle relaxer saccinylcholine

active approach 3 rd stage

administering oxyticin when the anterior shoulder is birthed or immediately following the birth of the fetus clumping and cutting the umbilical cord within 3 min after birth gently controlling cord traction followwing uterine contraction and separation of the placenta

IM route

advantages - quick administration no need for IV line disadvantages: - onset of pain relief is delayed - higher doses are required - medication is released at an unpredictable rate

fetal adaptation to labor/ fetal circulation

affected by maternal position, contractions, maternal BP, umbilical cord blood flow. contractions - decrease flow fetus can compensate

disadvantages spinal anesthesia

allergy hypotension ineffective breathing pattrn possible cardiopulmonary rescusitation after birth uterine atony postdural puncture headache Leakage of CSF fluids from the site of the dura mater is thought to be a causative factor of Postdural puncture headache ( PDPH). TX: oral analgesics, methylxanthines ( ex: IV caffeine or theophylline) or an epidural blood patch. supine position reliefs headache, hydration, bed rest blood patch if headache is severe

analgesia

alleviation of pain sensation or raising of the pain threshold without loss of consciousness.

Oligohydramnios

an abnormally small amount of amniotic fluid

Opioid agonist-antagonist analgesics

an agonist is an agent that activates or stimulates a receptor to act; an antagonist is an agent that blocks a receptor or a medication designed to activate a receptor. butorphanol (Stadol) nalbuphine (Nubain) Opioid agonist-antagonist opioid analgesics, especially nalbuphine (Nubain), is not suitable for women with an opioid dependence because the antagonist activity could predipitate withdrawal symptoms in both the mother and her newborn ceiling effect - higher doses do not produce respiratory depression

spinal anesthesia

an anesthetic solution containing a local anesthetic alone or in combination with an aopiod agaonist analgesic is injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space, where the anesthetic solution mixes with cerebrospinal fluid

Fetal monitoring of a pregnant client revealed a regular smooth, undulating wavelike pattern of the fetal heart rate. What should the nurse infer about the fetus from these results? Anemia. Ischemia. Hypertension. Hypotension

anemias Rationale A regular smooth, undulating wavelike pattern in the FHR is referred to as a sinusoidal pattern. This uncommon pattern mostly occurs with severe fetal anemia. Ischemia refers to impaired circulation. FHR pattern cannot indicate this condition. Blood pressure level below 120/80 mmHg indicates hypotension. Blood pressure level above 120/80 mm Hg indicates hypertension. The FHR pattern cannot indicate conditions such as hypotension or hypertension.

nitrous oxide

anesthetic gas mixed with oxygen, which is inhaled beginning 30 seconds before the onset of a contraction to reduce but not eliminate pain during the first and second stages of labor

Opioid analgesics

are effective for releiving severe, persistent or recurrent pain by blunting the perception of pain, though not elimating it completely hydromorhone hydrochloride (Dilaudid) meperidine (Demerol)

Which technique can the nurse use to stimulate the fetus and accelerate the fetal heart rate (FHR)? Discontinue the administration of oxytocin. Place the client in the knee chest position. Administer medications for tocolytic therapy. Use a halogen light over the maternal abdomen.

Use a halogen light over the maternal abdomen. Rationale The nurse may place a specialized halogen light source on the maternal abdomen to stimulate the fetus and accelerate the FHR by at least 15 beats/minute for at least 15 seconds. Oxytocin infusion is discontinued to reduce uterine contractions. The client is placed in the knee chest position to relieve compression on the umbilical cord. Tocolytic therapy involves the administration of drugs that inhibit uterine contractions. They are used to relax the uterus.

Which factors contribute to an increase in a client's pain tolerance level? Select all that apply. Need for epidural analgesia Use of relaxation techniques Desire for natural vaginal birth Quiet and relaxed ambience Use of pharmacologic methods

Use of relaxation techniques Desire for natural vaginal birth Quiet and relaxed ambience Rationale Pain tolerance refers to the level of pain a laboring woman is willing to endure. The factors that influence a woman's pain tolerance level include desire for a natural vaginal birth, use of relaxation techniques for comfort, and the quiet and relaxed ambience during labor. If the client has reduced pain tolerance, the client is likely to ask for pharmacologic interventions for pain relief. Epidural analgesia is used to relieve pain experienced during natural vaginal birth.

Local anesthesia

Used for blocking pain during episiotomy. Administered just before birth of infant No effect on fetus

General anesthesia

Used for surgical interventions. Mother not awake - Maternal danger of respiratory depression, vomiting and aspiration.

A nurse is caring for a patient who undergoes general anesthesia. Which adverse effects associated with general anesthesia should the nurse monitor for? Select all that apply. Uterine relaxation Respiratory depression Inadequate pain control Prolonged postpartum fatigue Maternal aspiration of gastric contents

Uterine relaxation The nurse should monitor for uterine relaxation, which is an adverse effect of general anesthesia. Respiratory depression The nurse should monitor for respiratory depression, which is an adverse effect of general anesthesia Maternal aspiration of gastric contents The nurse should monitor for maternal aspiration of gastric contents, which is an adverse effect of general anesthesia.

Which elements can be assessed to determine placental separation? Select all that apply. Uterine shape Uterine location A foul-smelling discharge Amount of blood flow from the vagina Discharge containing large pieces of tissue

Uterine shape When the infant is born, the uterine cavity becomes much smaller. Uterine location The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. Amount of blood flow from the vagina A gush of blood appears as blood trapped behind the placenta is released.

The nurse is monitoring the fetal heart rate (FHR) of a client and notices late decelerations, including a gradual decrease in and return to baseline, associated with uterine contractions. To which condition does the nurse attribute this? Fundal pressure Uteroplacental insufficiency Vaginal examination Fetal scalp stimulation

Uteroplacental insufficiency Rationale Uteroplacental insufficiency leads to disruption of the oxygen transfer from the maternal blood to the fetus. This can lead to late decelerations of the fetal heart rate. Early FHR decelerations may be caused by fetal head compression caused by fundal pressure or vaginal examination. Fetal scalp stimulation typically causes FHR accelerations, not late FHR decelerations.

The nurse is assisting the primary health care provider during the labor process. Which lacerations does the nurse expect in a client who has suffered perineal lacerations? Vaginal lacerations Cervical lacerations Urethral lacerations Vaginal vault lacerations

Vaginal lacerations Rationale A laceration is an irregular tearing of tissues during childbirth. Because the perineum lies below the vagina, lacerations to the perineum may also affect the vagina. Therefore, vaginal lacerations are often associated with perineal lacerations. Cervical lacerations occur at the lateral angles of the external os when the cervix retracts over the advancing fetal head. Urethral lacerations are uncommon or rare during a normal labor process, because they are situated anteriorly. Vaginal vault lacerations may result from rapid fetal descent, precipitous birth, or the use of forceps to rotate the fetal head.

After observing the fetal heart activity in the electronic fetal monitor, the nurse suspects that the client's umbilical cord is compressed. What did the nurse observe on the monitor? Variable decelerations Increase in the fetal heart rate Decrease in the fetal heart rate Early decelerations

Variable decelerations Rationale A compressed umbilical cord is commonly observed at the time of labor, which can be determined by variable decelerations in the FHR. Variable decelerations are seen as W- or U-shaped waves on the monitor. The heart rate is not affected due to umbilical cord compression. Early decelerations in the FHR are observed when head of the fetus is compressed.

While monitoring the fetal heart rate, the nurse instructs the client to change her position and lie in the knee-to-chest position. What is the reason for the nurse to give this instruction to the client? Late decelerations in the fetal heart rate. Variable decelerations in the fetal heart rate. Early decelerations in the fetal heart rate. Prolonged decelerations in the fetal heart rate.

Variable decelerations in the fetal heart rate. Rationale Variable decelerations in the fetal heart rate are usually caused by umbilical cord compression. The knee-to-chest position is useful for relieving cord compression, and thus the nurse should ask the client to move into this position. Prolonged decelerations in the fetal heart rate are not affected by the mother's position. If the nurse finds late decelerations in the fetal heart rate, the nurse should ask the mother to lie in the lateral position. Early decelerations in the fetal heart rate are a normal finding, and no nursing intervention is required.

Fetal bradycardia is common during what problem? Maternal hyperthyroidism Fetal anemia Viral infection Tocolytic treatment using ritodrin

Viral infection Rationale Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, viral infections such as cytomegalovirus (CMV), maternal hypothermia, and maternal hypothermia. Maternal hyperthyroidism will most likely result in fetal tachycardia. Fetal anemia will most likely result in fetal tachycardia. Tocolytic treatment using ritodrine will most likely result in fetal tachycardia.

Early Deceleration

Visually apparent gradual decrease in and return to baseline FHR associated with uterine contractions -normal finding -caused by fetal head compression -onset to lowest point greater than 30 seconds -Recovery corresponds with the end of the contraction -Onset (lowest point) corresponds with beginning of the contraction -Mirror image of contraction

Standard precautions during childbirth:

Wash hands before/after exam Gloves Mask that has a shield or protective eyewear and gown during birth Wear gloves and gown when handling the newborn immediately after birth

After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is called what? Visceral Referred Somatic Afterpain

Referred Rationale As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

Fetal monitoring of a pregnant client revealed that the fetal heart rate has minimal variability. Which prescribed drug is most likely responsible for the condition? Hydroxyzine (Vistaril) Terbutaline (Brethine) Secobarbital (Seconal) Atropine (Sal-Tropine)

Secobarbital (Seconal) Rationale Variability in the fetal heart rate can be classified as absent, mild, or moderate variability. This results in hypoxia and metabolic acidemia in the fetus. Central nervous system (CNS) depressants, such as secobarbital (Seconal), cause decreased variability in the fetal heart rate. This medication affects the baseline heart rate in the fetus by less than 5beats/minute. Hydroxyzine (Vistaril), terbutaline (Brethine), and atropine (Sal-Tropine) may result in tachycardia in the fetus. These drugs can increase the baseline fetal heart rate as much as 25 beats/minute.

A pregnant client is experiencing somatic pain during labor that is intense, sharp, and burning. Which stage of labor is associated with this type of pain? First Third Fourth Second

Second Rationale In the second stage of labor, the patient experiences somatic pain. The pain occurs due to stretching and distention of the perineal tissues and the pelvic floor to allow the passage of the fetus. The pain also occurs due to the distention and traction on the peritoneum and the uterocervical supports during contractions. The client experiences less discomfort and is free of pain between contractions in the first stage of labor. In the third stage, the pain is similar to the pain experienced in the first stage. In the fourth stage, the client recovers physically from the birth and may experience pain if there are any complications.

Nurses should be aware of the difference a woman's experience with labor can make in labor pain, such as what? Sensory pain for nulliparous women often is greater than for multiparous women during early labor Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor Women with a history of substance abuse experience more pain during labor Multiparous women have more fatigue from labor and therefore experience more pain

Sensory pain for nulliparous women often is greater than for multiparous women during early labor

Nurses should be aware of the difference experience can make in labor pain, such as what? Sensory pain for nulliparous women often is greater than for multiparous women during early labor. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. Women with a history of substance abuse experience more pain during labor. Multiparous women have more fatigue from labor and therefore experience more pain.

Sensory pain for nulliparous women often is greater than for multiparous women during early labor. Rationale Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Place the feedback loop events responsible for labor contractions at term in the order of their expected occurrence. The fundus of the uterus contracts. The fetal head pushes against the cervix. Oxytocin is increasingly secreted. The fetal head stretches the cervix.

The fetal head pushes against the cervix. The fetal head stretches the cervix. Oxytocin is increasingly secreted. The fundus of the uterus contracts. A feedback loop is probably responsible for labor contractions at term: the fetal head stretches the cervix, causing the fundus of the uterus to contract, further pushing the fetal head against the cervix, and causing more fundal contractions. Cervical stretching also causes secretion of oxytocin, thereby causing more contractions.

Which is an abnormal finding in a fetus during labor? The fetal heart rate is 190 beats/minute at term. The fetal head is in a synclitic position. The fetal oxygen pressure decreases. The fetal circulation is decreased.

The fetal heart rate is 190 beats/minute at term. Rationale The normal range of fetal heart rate is 110 to 160 beats/minute at term. Therefore, 190 beats/minute is an abnormal finding in the fetus. The fetal head is usually in a synclitic position, which indicates that the head is parallel to the anteroposterior plane of the pelvis. The oxygen pressure decreases as the fetal lung fluid is cleared from the air passage during the birth process. This aids in immediate respiration after birth. The fetal circulation tends to decrease during labor because of uterine contractions.

A nurse's initial evaluation of a newborn following delivery reveals an Apgar score of 8. How should the nurse interpret this score? The infant is in severe distress. The infant is having moderate difficulty. The infant is adjusting well to extrauterine life. The infant is in need of emergency resuscitation.

The infant is adjusting well to extrauterine life. Apgar scores of 7 to 10 indicate the infant is adapting well to extrauterine life.

Match the supportive nursing interventions with their rationales.

The nurse constantly monitors FHR for reassuring and nonreassuring patterns. Assess the FHR for baseline and for variability and periodic changes. The nurse uses this to obtain more accurate information about uterine contractions. Assess the measurements taken by the IUPC. Maternal fever can affect the fetus. Assess the mother's temperature. To make sure that the uterus is contracting at a normal frequency, normal duration, normal intensity and normal uterine resting tone. Assess the mother's uterine activity.

The nurse is using pain-relief methods based in the gate-control theory of pain while assisting a pregnant client in labor. Which action by the nurse is in accordance with this theory? The nurse encourages the client to use imagery during labor. The nurse encourages the client to shower with warm water. The nurse administers opioid analgesic to the client. The nurse adjusts the lights and noise as per the client's preference.

The nurse encourages the client to use imagery during labor. Rationale According to the gate-control theory of pain, pain sensations travel to the brain along the sensory nerve pathways. However, only a limited number of pain sensations can travel at a time. The use of imagery during labor blocks the capacity of the nerve pathways to transmit the pain. Imagery helps close the hypothetic gate in the spinal cord and prevents pain signals from reaching the brain. Showering is not related to the use of the senses to achieve pain control. The use of opioid analgesic is a pharmacologic measure of relieving pain. The gate-control theory of pain is based on the use of sensory organs to relieve pain and does not depend on the adjustment of environmental factors like lights and noise.

The nurse is caring for a woman who is receiving oxytocin. The electronic fetal monitor is showing that the contractions are approximately 10 seconds apart. Which would the nurse do next? The nurse would stop oxytocin. The nurse should call the health care provider. The nurse should reposition the woman to her side. The nurse should administer oxygen to the woman.

The nurse would stop oxytocin. One of the side effects from oxytocin or other uterine stimulants is excessive uterine activity which can be harmful to mother and fetus. Therefore, the first action would be to stop the medication.

In a variation of rooming-in called couplet care, the mother and infant share a room and the mother shares the care of the infant with: The father of the infant. Her mother (the infant's grandmother). Her eldest daughter (the infant's sister). The nurse.

The nurse. In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room maternity care. The father is included in instruction regarding infant care whenever he is present. The grandmother is welcome to stay and take part in the woman's postpartum care, but she is not part of the couplet. An older sibling may stay with the client and her baby but is also not part of the couplet.

A vaginal exam during labor reveals the following information: LOA, -1, 75%, 3cm. An accurate interpretation of this data would include which of the following? (all that apply) a. Attitude: flexed b. Station: 3cm below the ischial spines c. Presentation: cephalic d. Lie: longitudinal e. Effacement: 75% complete f. Dilation: 9cm more to reach full dilation

a. Attitude: flexed c. Presentation: Cephalic d. Lie: Longitudinal e. Effacement: 75% complete Station is 1cm above the ischial spines (-1); 3cm more to reach full dilation of 10cm

physical assessment during second stage

assess Q5-30 min- maternal BP.puls and RR FHR Q5-15; vaginal show, fetal decent, changes in maternal appearance Q10-15 min, every contraction and bear down effect

assessment during 4th stage of labor bladder

assess distention bu noting location and firmness distended - suprapubic rounded bulge, fluctuate like a water balloon, uterus will be boggy and to the right side assist woman to void and measure catherize if necessary reassess after voiding that the bladder is not palpable and uterus is firm

fentanyl nursing considerations

assess for respiratory depression naloxone antidote safety measures frequent dosing to to short half life max total dose 500-600 mg

intermitten auscultation

assessing baseline FHR, rhythm, increase and decrease frm baseline uterine activity assessed by palpation

Unbilical cord acid base determination

assessment method used immediately after birth as an adjunct to the Apgar score; it measures pH, Po2, and Pco2 of the newborn's blood and reflects the acid base status of the newborn at birth

nursing care during 3rd stage of labor

assist to bear down to facilitate expulsion of the separated placenta; admin oxytocin as ordered to ensure adequate contraction of the uterus, thereby preventing hemorrhage; provide comfort and pain relief measures; perform hygienic cleansing measures; keep informed of progress of placental separation and expulsion and perineal repair if appropriate; explain purpose of meds administered; introduces parents to their baby and facilitate the attachment process by delaying eye prophylaxis; wrap mother and baby together for skin to skin contact; provide private time for parents to bond with new baby; encourage breastfeeding if desired

normal shape of newborn

assumed within 3 days after birth

Baseline FHR

average FHR range of 110 to 160 beats/min at term as assessed during a 10 minute segment that excludeds periodic or episodic changes and periods of marked variabililty

expectations after general anesthesia

awake, alert, oriented to time, place and person RR - normal O2 at least 95%

presenting part in presentation

cephalic - occiput breech - sacrum shoulder - scapula

Nerve block analgesia and anesthesia

chemically from cocaine, so the ending is "caine" temporary interruption of the conduction of nerve impulses (pain) examples bupivacaine, chloroprocaine, lidocaine, ropivacaine, allergic reaction rare but include - respiratory depression, hypotension keep epinephrine, antihistamines, oxygen, supportive measure nearby

phenothiazine

class of drug used to decrease anxiety, increase sedation, and reduce nausea and vomiting but which may impair the analgesic efficacy of opioid

Anxiety influence on pain response

considered normal for a woman during labor and birth. However, excessive anxiety cause more catecholmaine secretion, which increases the stimuli to the brain from the pelvis because of decreased blood flow and increased muscle tension. As anxiety and fear heighten, muscle tension increases_, the effectiveness of uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins

Moderate Variability of Heart Rate

considered normal- 6-25 bpm -presence is highly predictive of abnormal fetal acid-base balance (absence of fetal metabolic acidemia)

general flexion attitude

back of the fetus is rounded chin if flexed on the chest thighs are flexed on the abdomen legs are flexed at the knees the arms are crossed over the thorax umbelical cord between the arms and the legs

Water Therapy (Hydrotherapy)

bathing, showering, and jet hydrotherapy(whirlpool baths) with warm water are nonpharmacologic measures that can provide comfort and relaxation during labor stimulates release endophins, relaxes fibers and promotes better circulation best when woman is in active labor

frequency of contractions

beginning of one contraction to the beginning of the next

First stage of labor

begins with the onset of regular contractions and ends with full dilation. It is divided into 3 phases: latent, active, and transition.

engagement

biparietal diameter of the head passes the pelvic inlet - the head is engaged in the pelvic inlet nulliparous - before labor multiparous - after labor is established

cephalic presentation

birth position in which any part of the head emerges first 96% of births

breech presentation

birth position in which the buttocks, feet, or both emerge first 3% of births

passageways

birthcanal -mother's rigid bony pelvis and the soft tissues of the cervix, the pelvic floor, the vagina, the introitus ( external opening to the vagina)

Operculum

brownish or blood-tinged cervical mucoid discharge representing the passage of the mucous plug as the cervix ripens in preparation for labor.

fetal position, presentation and attitude examined

by palpation of fontanels and sutures during vaginal examination

maternal adaptations/ endocrine changes

decreasing levels of progesteron, increased estrogen, prostaglandins, oxytocin metabolism increases, blood glucose cam decreases during labor

hypoxemia

deficiency of oxygen in the arterial blood

flexion

descending head meets resistance from the cervix, pelvic wall, pelvic floor, so the chin flexes into closer contact with the fetal chest and permits smaller suboccipitobregmatic diameter to present to the putlet

Lightening

descent of the fetal presenting part into the true pelvis approximately 2 weeks before term in the primigravida and at the onset of labor in the multiparous woman.

subpubic angle

determines the type of pubic arch

expulsion uses

diaphragm and abdominal muscles increased intraabdominal pressure -> compresses uterus on all sides and add expulsive power

Pudental nerve block

dministered late in the second stage of labor, is useful if an episiotomy is to be performed or if forceps or a vaccum extractor is to be used to facilitate birth. It can also be administered during the ____ stage of labor if an episiotomy or lacerations must be repaired. You have to be really careful when doing the pudendal block (huge needle have to stick back almost to the head of the femoral area) because they aren't able to pee and don't know they need to pee so you will really have to assess them for voiding. Make sure their able to go to the bathroom. A pudenda; nerve block should be administered 10 to 20 minutes before perineal anesthesia is needed. Pudendal block does NOT change maternal hemodynamic or respiratory functions, vital signs, or the FHR. However the ____ refelx is lessened or lost completely.

opioid antagonist

drug that promptly reverses the effects of opioids, including maternal and neonatal CNS depression especially respiratory depression

maternal adaptation/ renal changes

during labor - spontaneous voiding difficult due to: -tissue edema from pressure from the presenting part, discomfort, analgesia, embarassment protenuria 1+ ( muscle breakdown from physical work of labor)

maternal adaptation to labor/ cardiovascularduring

each contraction 400 ml of blood emptied from uterus to maternal cardiovascular ssytem by end of 1st stage cardiac output increased by 51%, peaks 10 to 30 min after birth, returns to prelabor baseline within postpartum hour, HR drops BPincrease during contractions return to baseline between them supine hypotension WBC increases

With regard to systemic analgesics administered during labor, nurses should be aware that: systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. effects on the newborn can include significant neonatal respiratory depression. IM administration is preferred over IV administration. IV client-controlled analgesia (PCA) results in increased use of an analgesic.

effects on the newborn can include significant neonatal respiratory depression. Rationale Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

Extension

enables the head to emerge when the fetus is in a cephalic position and it begins after the head crowns. is complete when the head passes under the symphysis pubis and occiput, and the anterior fontanel, brow, face, and chin pass over the sacrum and coccyx and are over the perineum.

anesthesia

encompasses analgesia, amnesia, relaxation, and reflex activity. Anesthesia abolishes pain perception by interrupting the nerve impulses to the brain. The loss of sensation may be partial or complete, sometimes with the *loss of consciousness.

endorphins

endogenous opioids secreted by the pituitary gland that act on the central and peripheral nervous systems to reduce pace

mechanism of labor - cardinal movements

engagement flexion internal rotation extension restitution and external rotation expulsion

Patterned-Paced or Pant-Blow Breathing

enhanced concentration (cperformed at about twice the normal breathing rate ) 3:1 patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW ( repeat) 4:1 patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat) undesired reaction - hyperventilation - look for respiratory alkalosis ( lightheadedness, dizziness, thingling of the fingers, circumoral numbness) . to eliminate it - ask to breath into a brown bag

nurses obligations during 3rd stage

examine placenta that nothing is left inside draw cord blood lacerations repair breathing relaxation techniques baby assessment bands matching eye prophilaxis, weighing baby, vitamin K after bonding

variability

expected irregular fluctuations in the baseline FHR of 2 cycles per minute or greater as a result of the interaction of the sympathetic and parasympathetic nervous systems

abbreviation of position

first letter - location of the presenting part (R or L) of mother's pelvis second letter - specific presenting part of the of the fetus ( O- occiput, S - sacrum, M - mentum/chin, Sc - scapula/ shoulder) final letter - location of the presenting part in relation to the anterior (A), posterior (P) or transverse (T) portion of the maternal pelvis ROA - occiput is the presenting part and is located in the right anterior quadrant of the maternal pelvis LSP - sacrum is the presenting part and is located in the left posterior quadrant of the maternal pelvis

hypnosis

form of deep relaxation, similar to daydreaming or mediation; the person enters a state of focused concentration and the subconscious mind can be more easily accessed.

bony pelvis

formed by the fusion of the ilium, the ischium, the pubis, and the sacral bones

uterine contractions description

frequency intensity duration resting tone

third stage of labor

from birth of the fetus until the placenta is delivered

second stage of labor

from full dilation to birth

deep cleansing breath

full breath taken at the beginning of a contraction to greet it and end of each contraction to blow it away

partogram

graphic chart on which cervical dilation and station are plotted to assist in early identification of deviations from expected labor patterns

maternal adaptation/respiratory changes

greater oxygen consumption, increased RR hyperventilation may cause respiratory alkalosis ( increase pH), hypoxia, hypocapnia ( decrease carbon dioxide) unmedicated woman during 2nd stage - oxygen consumption doubles

minimal variability

greater than undetected but not more than 5 beats/min

Intrauterine resuscitation

group of interventions initiated when an abnormal (nonreassuring) FHR pattern is notes to improve uteroplacental perfusion and increase maternal oxygentation and cardiac output. Basic corrective measures include supplemental oxygen, maternal position change, and increasing IV infusion rate

goal of intrapartum FHR

identify and differentiate the normal (assuring) from abnormal ( nonreassuring) patterns indicating fetal compromise

episiotomy

incision to perineum to enlarge the vaginal outlet; done immediately before birth because perineal musculature greatly distended, to minimize soft tissue damage

maternal adaptations/ neuro

initially euphoretic, seriousness and amnesia between contractions elation, fatigue aftr giving birth endogenous endorphins raise pain threshhold and produce sedation anesthesia decrease pain

intrathecal analgesia

injection of an opioid agonist analgesic into the spinal fluid to relieve pain associated with labor and following cesarean birth

intradermal water block

injection of small amounts of sterile water (0.05 to 0.1 ml) using a fine needle ( 25 gauge) into four locations on the lower back to relieve low back pain intense stinging 20-30 sec after injection relief 2 hr

Amnioinfusion

instillation of room temperature isontonic fluid into the uterine cavity if the volume of the amniotic fluid is low to relieve intermitten cord compression that results in variable decelerations and transient fetal hypoxemia

true pelvis

involved in birth - the inlet/brim - midpelvis/cavity - outlet

TEN

involves the placing of two pairs of flat electrodes on either side of the woman's thoracic and sacral spine continuous impulses high intensity will help release endophins for back pain during 1st stage

Flexion

is a process of nodding of the fetal head forward toward the fetal chest.

Effleurage

is light stroking, usually of the abdomen, in rhythm with breathing during contraction if she has monitors use thigh or chest

Restitution

is realignment of the fetal head with the body after the head emerges.

Counterpressure

is steady pressure applied by a support person to the sacral area with a frim object or the fist or heel of the hand also can be applied to both hips, knees lifts occiput off the nerves

Engagement

is the mechanism whereby the fetus nestles into the pelvis. also is termed lightening or dropping.

Fourth stage of labor

is the period of recovery when homeostasis is reestablished.

Descent

is the process that the fetal head undergoes as it begins its journey through the pelvis. is a continuous process from the time of engagement until birth and is assessed by the measurement called station.

posterior fontanel

junction of the sutures of the two parietal bones

assessment during 4th stage fundus

knees flexed head flat just below umbilicus cup hand, press firmly at the same time as at the symphisis if fundus is firmand midline measure position related to umbolicus ( how many finger weidths) 1 cm above +1, below -1 if fundus is nt firm , massage to contract and expel clots

fourth degree perineal laceration

laceration that also involves the anterior rectal wall

third degree perineal laceration

laceration that continues through the anal sphincter muscle

second degree perineal laceration

laceration that extends through the muscles of the perineal body

first degree perineal laceration

laceration that extends through the skin and structures superficial to the muscles

anterior fontanel

largest diamond shaped 3 x 2 cm junction of the sagittal, coronal, frontal sutures closes by 18 months

biparietal diameter

largest transverse diameter of the fetal head; measured between the parietal bones in cephalic presentation - widest part of the head entering the pelvic inlet 9.25 cm

Biparietal diameter

largest transverse diameter of the fetal skull. suboccipitobregmantic diameter is smallest diameter of the fetal skull to enter the maternal pelvis when the fetal head is in complete flexion.

Third stage of labor

lasts from the birth of the fetus until the delivery of the placenta

Second stage of labor

lasts from the time the cervix is fully dilated to the birth of the fetus.

second stage phases

latent - passive fetal descent through the birth canal and rotate to an anterior position active pushing

Two phases of second stage of labor

latent, active

pain tolerance

level of pain a person is willing to accept when level exceeds, the person is seeking for pain relief

effleurage

light stroking of the abd. or other body part in rhythm with breathing during contractions

disadvantages of epidural block

limited control of labor and movemnts orthostatic hypotension ( administer oxygen) or uteroplacental perfusion and oxygen to fetus dizziness sedation weakness of legs fever accidental injection into blood vessel or into subarachnoid space ( totsl anesthesia) urinary retention stress incontinence difficulty eleminating pruritus

position to deal with complications

lithotomy buttocks to the edge of the bed legs in stirrups no pressure on popliteal space pad stirrups

vaginal birth meds

local infiltration anesthesia pudential block epidural block analgesia and anesthsia spinal block anesthesia CSE analgesia and anesthesia nitrous oxide

transverse/ horisontal/oblique

long axis of the fetus is at a right angle diagonal to the long axis of the mother

fetal adaptation to labor/ fetal respirations

lung fluid is cleared from the air passages as the infant passes through the birth canal during labor fetal oxygen pressure decreases arterial carbon dioxide pressure increases arterial pH decreases bicarbonate level decreases fetal respiratory movements decrease during labor

nursing examination/ transition phase

maternal BP, pulse, RR - Q15-30 min FHR and pattern Q 15-30 min uterine activity, presence of vaginal show Q 10-15 min changes in maternal appearance, mood, affect, energy level, condition of partner - Q 5 min Temp Q4h until membrance raptures, then Q2h vaginal examination - as needed

nursing assessment/ active phase

maternal BP, pulse, RR - Q30 min FHR and pattern, uterine activity, presence of vaginal show Q 15-30 min changes in maternal appearance, mood, affect, energy level, condition of partner - Q 15 min Temp Q4h until membrance raptures, then Q2h vaginal examination - as needed

nursing assessment/ latent phase

maternal BP, pulse, RR, FHR and pattern, uterine activity, presence of vaginal show - every 30-60 min changes in maternal appearance, mood, affect, energy, condition of partner - every 30 min temperature - every 4 hrs until membrane raptures, then every 2 hrs vaginal examination - as needed

Causes of Prolonged Decelerations

maternal hypotension -uterine tachysystole -extreme placental insufficiency -prolonged cord compression or prolapse immediately notify MD

Naloxone (Narcan) adverse effects

maternal hypotension or hypertension tachycardia hyperventilation nausea and vomiting sweating tremulousness

Deceleration

may be benign or abnormal -categorized as early, late, variable, or prolonged -described by their visual relation to the onset and end of a contraction and by their shape

local perineal infiltration anesthesia

may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia 10-20 ml of 1% lidocaine SQ into the region anesthesized epinephrine added to prevent bleeding and systemic absorption

Nubain (Nalbuphine Hydrochloride) nursing considerations

may precipitate withdrawal symptoms in opioid dependent women assess maternal vitalsigns, degreee of pain, FHR and uterine activity before administering observe for maternal respiratory depression encourage voiding every 2 hrs palpate for bladder distention if birth 1-4 hrs after meds, observe baby's repiratory depression, safety measure

Stadol (nursing considerations)

may precipitate withdrawal syndrome in opioid dependant moms assess maternal vital signs, degree of pain FHR, uterine activity before administration observe for maternal respiratory depression encourage voiding every 2 h palpate bladder for distension if birth within 1-4 hrs - observe newborn for respiratory depression safety measures

midline episiotomy

median; most commonly used in the US; effective, easily repaired, and generally the least painful; also associated with a higher degree of third and fourth degree lacerations

fontanels

membrane filled spaces between cranial bones in infants

opioid agonist analgesics

meperidine fentanyl - no amnesic effect - euphoris rest between contractions not to administer before labor is established

IV administration pain reliever

meperidine fentanyl nalbuphine slowely small doses during 3-5 contractions ( to reduce fetal exposure) onset of pain relief is fast and predictable pain relief obtained with small doses duration of effect is predictable

intermitten auscultation

method of listening to fetal heart sounds at periodic intervals to assess the FHR using a Leff scope, DeLee-Hillis fetoscope, or an ultrasound device

Fetal scalp blood sampling

method used to obtain fetal blood in order to assess the pH of the blood

autologous epidural blood patch

method used to repair a tear or hole in the dura mater around the spinal cord as a result of spinal anesthesia; the goal is to prevent or treat postdural puncture headaches (PDPHs)

Types of episiotomy

midline and mediolateral

nitrous oxide

mixed with oxygen can be inhaled in a low concentration to provide analgesia during the first and second stages of labor. At the lower doses used for analgesia, it helps women relax, gives them a sense of control, and reduces their perception of pain even though they may still be aware their pain is present. 1-2 stages

second stage meds

nerve block analgesia and anesthesia local infiltration anesthesia pudental block spinal block anesthesia epidural block anesthesia CSE analgesia nitrous oxide

advantage spinal anesthesia

no fetal hypoxia, easy administration, maternal consciousness, good muscular relaxation, blood loss is not exessive

hydrotherapy

nonpharmacologic comfort measure that uses the buoyancy of the warm water to provide support for tense muscles, relief from discomfort, and general body relaxation

biofeedback

nonpharmacologic pain control technique based on the premise that a person can recognize his or her body's physical signals and use mental processes to change or control certain internal physiologic events.

transcutaneous electrical nerve stimulation (TENS)

nonpharmacologic pain control technique that involves placing two pairs of electrodes on either side of the woman's thoracic and sacral spine to provide continuous low-intensity electrical impulses or stimuli that can be increased during a contraction

acupressure

nonpharmacologic pain control technique that is based on the application of pressure, heat, or cold on specific body points called tsubos

clinical significance of early descelerations/ nursing interventions

normal patter no need for interventions

Epidural and spinal opioids ( intrathecal)

opioids used alone, eliminating the affects of a local anesthetic, do not cause maternal hypotension or affect vital signs feel contractions but not pain can bear down, motor power intact common indication - postoperative pain may require meds for breakthorugh pain Intrathecal goes in like an epidural in the dura mater space in the back into a little space right before the dura mater. Inject fentanyl or sublimaze and it causes these moms to be VERY sick.Very short acting usually giving at 8 to 9cm

Approximate Normal Values for Cord Blood- Artery

pH 7.2-7.3 PCO2 45-66 PO2 15-25 Base deficit <12

Approximate Normal Values for Cord Blood- Vein

pH 7.3-7.4 PCO2 35-45 PO2 25-35 Base Deficit <12

Acidemia Values

pH <7.20

modified paced breathing

paced breathing technique during which the woman breathes at an accelerated rate which should not exceed twice her resting respiratory rate

slow-paced breathing

paced breathing technique during which the woman breaths at approximately half her normal rate. it is usually the first technique used in early labor when the woman can on longer talk or walk her way through a contration

patterned-paced (pant-blow) breathing

paced breathing technique that combines breaths and puffs in a ration as a means to enhance concentration during the transition phase of the first stage of labor

5 factors affecting the process of labor and birth

passenger, passageway, powers, position of mother, and psychologic response

passive approach 3rd stage

patiently watching for signs that the placenta has separated from the uterine wall spontaneously and monitoring for spontaneous expulsion reduce risk of hemorrhae

internal rotation

pelvic inlet widest ibt eh transverse diameter, so fetal head passes it in the occipitotransverse position outlet widest anteroposteriorly - face must rotate posteriorly, occiput rotates anteriorly occiput will be midline beneath the pubic arch

internal force affecting birth

physiology/sensations

Duncan mechanism

placenta first appears on dark roughened maternal surface

fascilitating passage through the birth canal

position altered during labor ( of shoulders), so one shoulder occupy a lower level than the other it creates diameter smaller then the skull

sedatives

relieve anxiety and induce sleep 1. barbiturates: secobarbitoal sodium (Seconal) side effects - respiratory and vasomotor depression, affecting woman and newborn, rarely given 2. Phenothiazines: promethazine(Phenergan) - do not relieve pain, not recommended with analgesics 3. hydroxyzine(Vistaril) 4. Antiemetic: Metoclopramide (Reglan) Ondansetron (Zofran) 5. Benxodiazepines: diazepam(Valium), lorazepam(Ativan) - with opioid enhance pain relief and reduce nausea and vomiting, due to amnesi should avoid during labor in newborns - disrupts thermoregulation FLUMAZENIL - reverse benzodiazepines

epidural block types

repeaded injection continuous type - most common PCA

absent variability FHR

undetected variability

ambulating

upright position and ambulating have been associated with improved uterine contraction intensity and shorter labors, less need for pain medications, reduced rate of operative birth, increased maternal autonomy and control, distraction from other discomforts of labor, and an opportunity for close interaction with the woman's partner and care provider as they help her assume the position. If a woman does not change position every 30 to 60 minutes, assist her to do so.

signs of second stage of labor

urge to push or feeling the need to have a bowel movement sudden appearance of sweat on upper lip vomiting increased bloody show shaking of extremities increased restlessness

aromatherapy

use of essential oil from plants, flowers, herbs, and trees to promote health and well-being, enhance relaxation and treat illness

Interventions for Abnormal Fetal Heart Rate Pattern During the Second Stage of Labor

use open-glottis pushing -use fewer pushing efforts during each contraction -make individual pushing efforts shorter -push only with every other or every third contraction -push only with perceived urge to push

uterus before labor

uterine body ( corpus) cervix ( nack)

pain origins

visceral somatic

variable deceleration

visually abrupt FHR decrease any time during a contraction in response to umbilical cord compression

acceleration

visually apparent abrupt increase in the FHR of at least 15 beat/min or greater above the baseline rate that lasts 15 seconds or more with return to baseline less than 2 minutes from the beginning of the increase

prolonged deceleration

visually apparent decrease in the FHR of 15 beats/min or more below the baseline, that lasts more than 2 min but less than 10 min

late deceleration

visually apparent gradual FHR decrease after the start of a uterine contraction in response to uteroplacental insufficiency; the lowest point occurs after the peak of the contraction and baseline rate is not usually regained until the uterine contraction is over

early deceleration

visually apparent gradual FHR decrease starting with the onset of a contraction in response to fetal head compression

nurse must monitor for allergic reaction

vital signs respiratory effort cardiovascular status integument platelet and white blood cell count drowziness dyspnea

application of heat and cold

warmed blankets, compresses, heated rice bags, warm bath or shower heat relieves ischemia and increases blood flow cold - frozen gel packs, cold cloth applied to the back the chest or the face cooling reduces muscles temperature and relieving muscle spasm

nursing interventions/fluids

water __ immersion during active labor is associated with a decrease in the use of analgesia and reports of less maternal pain. Practice allows __ or __ or NPO during the active phase of labor when concern arose regarding the risk of anesthesia complications and their secondary effects, if general anesthesia were required in an emergency (aspiration) The process of labor slows when adequate __ and __ are not met with a rapid development of hypoglycemia and ketosis and fat is metabolized chemomile __ tea can enhance relaxation lemon balm __ or peppermint tea can reduce nausea ginger Teas of __ or ginseng root are energizing

previous experience affect on pain response

with pain and childbirth may affect a woman's description of her pain and her ability to cope with the pain. during first time - it will be her first experience with strong pain and she didn't develop coping mechanisms

spinal anesthesia inteventions

woman cannot feel contractions - instruct when to bear

Naloxone (Narcan) nursing considerations

woman should delay breastfeeding until meds are out of system (app 2 hrs) do not give to opioid dependent if given to reverse - pain wil retyrn short duration so monitor for respiratory depression

Japanese

women may be stoic in response to labor pain, but they may request medication when pain becomes severe.

Hispanic

women may be stoic until late in labor, when they may become vocal and request pain relief.

Southeast Asian

women may endure severe pain before requesting relief.

African American

women may express pain openly. Use of medication for pain relief varies.

External version

•Indicated for an abnormal presentation that exists after the thirty-fourth week. manipulation of the fetus from the unfavourable presentation into a favourable presentation for birth •Monitor vital signs. •If the mother is Rh-negative, ensure that Rho(D) immune globulin (RhoGAM) was given at 28 weeks' gestation. •Prepare for a nonstress test to evaluate fetal well-being. •Intravenous fluids and tocolytic therapy may be administered to relax the uterus and permit easier manipulation of the fetus. •Ultrasound is used during the procedure to evaluate fetal position and placental placement and guide direction of the fetus. •The abdominal wall is manipulated to direct the fetus into a cephalic presentation if possible. •Monitor blood pressure to identify vena cava compression. •Monitor for unusual pain.

Nonreassuring Fetal Heart Rate Patterns

■ Bradycardia ■ Tachycardia ■ Late decelerations ■ Prolonged decelerations ■ Hypertonic uterine activity ■ Decreased or absent variability ■ Variable decelerations falling to less than 70 beats/minute for longer than 60 seconds

The fourth stage of labor is considered to be the first _______________________________ after birth. During this stage the mother and newborn recover from the physical process of childbirth and get to know each other."

"5. 1 to 2 hours"

Which statement by the nurse is most effective in establishing a therapeutic relationship with a patient and her family when they first arrive to a birth center? "Please calm down. You are at the birthing center. We know what we are doing." "We have been very busy today. You will have to wait to talk about your birth plan." "Our priority is to deliver your baby safely. I cannot promise we will follow your birth plan especially if it is not written down." "After my initial assessment I would be happy to discuss your birth plan. First we want to make sure you and your baby are okay."

"After my initial assessment I would be happy to discuss your birth plan. First we want to make sure you and your baby are okay." The nurse has two priorities when the patient arrives at the birth center: (1) establishing a therapeutic relationship while (2) assessing the condition of the mother and fetus.

Hands-and-knees position

"All fours" which allows pelvic rocking. Relieves backache characteristic of back labor Facilitates internal rotation of the fetus by increasing mobility of the coccyx, increasing the pelvic diameters, and using gravity to turn the fetal back and rotate the head

Increment"

"Building up" of a contraction from its onset."

Nuchal cord

"Cord encircles the fetal neck."

A patient arrives at the Labor and Delivery unit and indicates she is nervous because this is the first time she has been to a health care provider since she became pregnant. Which response from the nurse is appropriate? "You are being very irresponsible by not seeking prenatal care." "Neglecting prenatal care could cost you the health of your baby." "Please establish care with a health care provider before coming back to the hospital." "Don't worry, we will take good care of you and help connect you with an appropriate health care provider."

"Don't worry, we will take good care of you and help connect you with an appropriate health care provider." The nurse should be supportive and respectful to the patient, even if the patient's values do not match the nurse's.

Duncan mechanism

"Expulsion of placenta with maternal surface emerging first."

A patient arrives at the intrapartum unit during an exceptionally busy night. Which statement from the nurse is appropriate? "We do not need to see your birth plan, as we do this every day." "Hi, my name is Pat, I will be helping you in any way I can tonight!" "We are very busy; it's too bad you could not have gone into labor last night!" "Please wait where you are and I will address your needs after my other patients'."

"Hi, my name is Pat, I will be helping you in any way I can tonight!" The nurse should communicate interest, friendliness, caring, and competence.

A patient is worried about the amount of equipment being used to monitor the fetus. Which statement should the nurse make to decrease anxiety? "I will explain each piece of equipment." "Don't be nervous; everything will be fine!" "This is the only way to identify a problem with the fetus." "This is the equipment needed for high-risk pregnancies."

"I will explain each piece of equipment." By providing information about the equipment to the parents, the nurse should be able to decrease the anxiety and reassure them.

B. Episiotomy

"Incision into perineum to enlarge the vaginal outlet."

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's best response? "Don't worry about it. You'll do fine." "It's normal to be anxious about labor. Let's discuss what makes you afraid." "Labor is scary to think about, but the actual experience isn't." "You may have an epidural. You won't feel anything."

"It's normal to be anxious about labor. Let's discuss what makes you afraid." Rationale Discussing the woman's fears allows her to share her concerns with the nurse and is a therapeutic communication tool. Telling the woman not to worry negates her fears and is not therapeutic. Telling the woman that labor is not scary negates her fears and offers a false sense of security. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: "Don't worry about it. You'll do fine." "It's normal to be anxious about labor. Let's discuss what makes you afraid." "Labor is scary to think about, but the actual experience isn't." "You may have an epidural. You won't feel anything."

"It's normal to be anxious about labor. Let's discuss what makes you afraid." This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. The statement in A negates the woman's fears and is not therapeutic. The statement in C also negates the woman's fears and offers a false sense of security. The statement in D is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A woman is at 38 weeks' gestation. She reports suspected signs of labor to the triage nurse. Which statement by the nurse supports the beginning of true labor? "Your contractions will decrease with activity." "The contractions will be mild and more annoying than painful." "You will feel the contractions in your front pelvic area and not in your back." "Labor contractions will occur in a consistent pattern that increases in frequency, duration, and intensity."

"Labor contractions will occur in a consistent pattern that increases in frequency, duration, and intensity." Contractions occurring in a consistent pattern of increasing frequency, duration, and intensity are a sign of true labor.

Decrement

"Letting down" of a contraction."

The health care team is administering naloxone hydrochloride (Narcan) to a pregnant client in labor to counter the adverse effects of opioids. What does the nurse inform the client? "Naloxone will cause a more rapid birth." "Naloxone will reverse the pain relief provided by the opioid." "Naloxone is likely to cause nausea and vomiting." "Naloxone may cause prolonged neonatal sedation."

"Naloxone will reverse the pain relief provided by the opioid." Rationale Naloxone hydrochloride (Narcan) is an opioid antagonist that will cause the pain that was relieved with opioids to resume. Naloxone does not cause a more rapid birth. Nausea and vomiting are the side effects of opioids, but will not be caused by naloxone itself. Meperidine hydrochloride (Demerol) causes prolonged neonatal sedation because it crosses the placenta.

Which statement does the nurse use to describe to the patient's partner why opioid analgesics are being administered? "Opioid analgesics prevent nausea." "Opioid analgesics remove the pain of labor." "Opioid analgesics help the mother relax between contractions." "Opioid analgesics reduce respiratory depression for the mother."

"Opioid analgesics help the mother relax between contractions." The nurse explains that opioid analgesics affect the perception of pain, allowing the mother to relax during contractions.

What instructions does the nurse give a client to ensure fetal safety during the second stage of labor? "Push continuously on command." "Hold your breath and push." "Push when you feel the urge." "Hold your breath and push with maximum effort."

"Push when you feel the urge." Rationale Fetal safety depends on the client's breathing patterns during the labor process, and on her bearing-down efforts. The nurse should ask the client to push instinctively and spontaneously to ensure more effective bearing-down efforts. This ensures the safety of the fetus by preventing hypoxia. The nurse should not ask the client to push continuously on command, because it may result in the client closing her glottis. The nurse should not ask the client to hold her breath and push, because it may increase intrathoracic and cardiovascular pressure. This would ultimately lead to fetal hypoxia. Telling the client to hold her breath and push with maximum effort before she feels the urge to push down is also discouraged, because this reduces cardiac output and decreases perfusion of the uterus and the placenta.

Which statement, if made by the nurse, can reduce a woman's anxiety during labor? "Susan, you can select the relaxation method you wish to use first." "More and more women have been electing to have cesarean deliveries." "You can try relaxation methods, but they do not work for most women." "Delivery of a baby is best done in a hospital with access to emergency equipment."

"Susan, you can select the relaxation method you wish to use first." Addressing the patient by name and offering her choices reduces a woman's anxiety during labor.

A. Modified Ritgen maneuver

"Technique used to control birth of fetal head and protect perineal musculature."

Which statement by the student nurse about the cervix indicates effective learning? "The cervix allows fetal descent into the vagina." "The cervix is the external opening of the vagina." "The cervix allows the fetus to rotate anteriorly." "The cervix distends and accommodates the intrauterine contents."

"The cervix allows fetal descent into the vagina." Rationale The cervix is a soft tissue that effaces (thins) and dilates (opens) to allow fetal descent into the vagina. The introitus is the external opening of the vagina. The pelvic floor muscles allow the fetus to rotate anteriorly and help it to pass through the birth canal. The lower uterine segment distends and accommodates the intrauterine contents when the wall of the upper segment thickens.

The patient is concerned by the use of the fetal scalp electrode and fears it will hurt the baby. Which is the best response by the nurse regarding the need for this assessment? "The fetal scalp electrode is only used in emergencies." "The fetal scalp electrode is less invasive and more accurate." "The fetal scalp electrode will provide more accurate information." "The fetal scalp electrode will stay firmly in place deep in the scalp of the fetus."

"The fetal scalp electrode will provide more accurate information." Explain to the parents how the fetal scalp electrode is more accurate than other fetal monitoring devices.

The nursing instructor asks a student about the different stages of labor. Which statement by the student indicates effective learning? "There is no abnormal bleeding in the first stage of labor." "The placenta is delivered in the fourth stage of labor after the birth." "The full effacement and dilation of the cervix indicates the beginning of the second stage." "The second stage lasts from full dilation of the cervix to the birth of the fetus."

"The second stage lasts from full dilation of the cervix to the birth of the fetus." Rationale The second stage of labor is composed of two phases: the latent (passive fetal descent) phase and the active pushing phase. In the latent phase, the fetus continues to descend passively through the birth canal, rotating in an anterior position due to the uterine contractions. In the active pushing phase, the fetus presses on the stretch receptors of the pelvic floor. Abnormal bleeding may sometimes occur in the first stage of labor which needs prompt attention by the primary health care provider. The placenta separates in the third stage of the labor after the birth of the fetus. The full effacement and dilation of the cervix ends at the first stage of the

The nurse can be sure that patient education has been effective when the woman states which as the main difference between a tocodynamometer and an intrauterine pressure catheter (IUPC)? "Only the tocodynamometer shows my uterine activity." "The tocodynamometer is much more accurate than the IUCP." "The tocodynamometer is applied externally to my abdomen, but the IUCP is inserted internally into my uterus to measure my contractions." "The tocodynamometer will be connected to my bedside monitor, but the IUPC is not."

"The tocodynamometer is applied externally to my abdomen, but the IUCP is inserted internally into my uterus to measure my contractions." Whereas the tocodynamometer is an external monitoring device, the IUPC is an internal monitoring device.

Match the laboring woman's description of her contraction pattern with the most likely phase.

"They don't bother me that much, but my belly tightens a little each time I have a contraction." Mild, every 5 min, lasting 30-40 sec "They are getting more intense. I have to breath with them and concentrate." Moderate, every 2-3 min, lasting 40-60 sec "They are so close together and they really hurt, I can't do this anymore." Strong, every 1½-2 min lasting 60-90 sec

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse verifies her understanding of the instructions when the woman makes what statement? "True labor contractions will subside when I walk around." "True labor contractions will cause discomfort over the top of my uterus." "True labor contractions will continue and get stronger even if I relax and take a shower." "True labor contractions will remain irregular but become stronger."

"True labor contractions will continue and get stronger even if I relax and take a shower." Rationale True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically, the contractions often stop with walking or a change of position.

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates her understanding of the instructions when the woman states: "True labor contractions will subside when I walk around." "True labor contractions will cause discomfort over the top of my uterus." "True labor contractions will continue and get stronger even if I relax and take a shower." "True labor contractions will remain irregular but become stronger."

"True labor contractions will continue and get stronger even if I relax and take a shower." True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions stop with walking or a change of position.

The nurse is assessing the fetal heart rate of a woman who is currently lying supine and notes a nonreassuring pattern. Which is the first recommendation by the nurse to address this pattern? "Elevate your legs." "Turn on your side." "Walk around the room to reposition the fetus." "Remain on your back and we will reassess in an hour."

"Turn on your side." The mother should not lie supine due to the compression of the aorta which could negatively affect the fetus. A change of position, such as lying on the side, is the first response to nonreassuring fetal heart rate pattern in this situation.

A pregnant client who is nearing her due date informs the nurse that she would like a vaginal delivery. The nurse observes in the medical records that the presenting part is the sacrum. What does the nurse tell the client? "Vaginal delivery may not be possible." "There will be no complications during labor." "You may have to lose weight for a safe delivery." "The infant may have congenital physical defects."

"Vaginal delivery may not be possible." Rationale If the presenting part of the fetus is the sacrum, it indicates a breech presentation. Vaginal delivery of a fetus in breech position carries increased risks and it is more likely that the client will have to have a caesarean delivery. It is inaccurate to inform the client that there will be no complications during the birth, because this is not something that the nurse can predict. A breech presentation does not indicate that the client needs to lose weight. Environmental and biologic factors are associated with congenital defects.

The sonographic reports of a client indicate that the fetus has a cephalic presentation. What does the nurse tell the client? "The fetal skull is not flexible." "There are fetal complications." "You may need a cesarean delivery." "Vaginal delivery will be the best choice."

"Vaginal delivery will be the best choice." Rationale In a well-flexed cephalic presentation, the biparietal diameter is the widest part of the head entering the pelvic inlet. When the head is in complete flexion, the fetal head is allowed to pass through the true pelvis easily. The fetal skull is flexible due to the open fontanels during birth. Fetal complications may be seen during labor if there is a forceps or vacuum-assisted birth, which may cause birth trauma.

opioid side effects

* respiratory depression * sedation * nausea/vomiting * dizziness altered mental status euphoria decreased gastric motility delayed gastric emptying urinary retantion use cautiously if she has respiratory and cardiovascular diseases they cross placenta - causing FHR variability, respiratory depression

The nurse assisting a laboring client is aware that the birth of the fetus is imminent. What is the station of the presenting part? -1 +1 +3 +5

+5 Rationale Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm.

powers

- involuntary- (primary powers) - beginning of labor - voluntary bearing down effeorts by the woman ( secondary powers) combined to expel the fetus and placenta from the uterus

nursing considerations after blood patch

- monitor vital sign, pallor, clammy hand, leakge of CSF )1-2 hrs) avoid coughing straining day after avoid meds preventing platelet aggregation for 2 daysm fluids, monitor for site infection

Category I Fetal Heart Rate Classification

-Baseline rate 110-160 bpm -Baseline FHR variability, moderate -Late or variable decelerations- absent -Early decelerations- either present or absent -Accelerations- either present or absent

Nursing Interventions for Late Decelerations

-Change maternal position (lateral) -Correct maternal hypotension by elevating legs -Increase rate of maintenance IV solution -Palpate uterus to assess for tachysystole -Discontinue oxytocin if infusing -Administer oxygen at 8-10 L/minute by nonrebreather face mask - Notify physician or nurse midwife -Consider internal monitoring for a more accurate fetal and uterine assessment -Assist with birth if the pattern cannot be corrected

Fetal Scalp Stimulation with Vibroacoustic Stimulation

-FHR acceleration in response to digital or vibroacoustic stimulation is highly predictive of a normal scalp blood pH -Can use digital pressure or vibroacoustic stimulation (using an artificial larynx or fetal acoustic stimulation device) -should not be done if FHR decelerations or bradycardia are present Desired result -An acceleration in the FHR of at least 15 bpm for at least 15 seconds -if desired result happens, indicates normal blood pH (lack of metabolic acidemia)

Interventions for Maternal Hypotension

-Increase the rate of the primary IV infusion -Change the lateral or Traendelenburg position -Administer ephedrine

Nursing Interventions for Fetal Tachycardia

-Reduce maternal fever with antipyretics (if this is the cause) -oxygen at 10 L/minute by nonrebreather face mask

Prenatal data

-Review the pregnancy information to provide personalized care -Take note of age -Pregnancy weight -Note if its her first birth -ANy pregnancy complications

Abnormal Fetal Heart Rate Patterns

-Those associated with hypoxemia -hypoxemia progresses into hypoxia and metabolic acidosis -Asphyxia ensues (when fetal hypoxia results in metabolic acidosis

Umbilical Cord Blood Acid-Base Determination

-blood is withdrawn from umbilical artery and umbilical vein after birth to test for pH, PCo2, PO2, and base deficit or excess -Umbilical artery values- reflect fetal condition -Umbilical vein values- indicate placental function Cord blood should be obtained in the following situations: -C-section birth for fetal compromise -low 5-minute APGAR score -sever IUGR -abnormal FHR tracing -maternal thyroid disease -intrapartum fever -multifetal gestation

Nursing Interventions for Variable Decelerations

-change maternal position (side to side, knee-to -chest) -discontinue oxytocin if infusing -Administer oxygen at 8-10 L/minute by nonrebreather face mask - Notify physician or nurse midwife -Assist with birth if the pattern cannot be corrected -assist with amnioinfusion if ordered -assist with vaginal or speculum examination to assess for cord prolapse

Somatic pain results from:

-distension and traction of the peritoneum and uterocervical supports during contractions -pressure against the bladder and rectum -stretching and distention of perineal tissues and the pelvic floor to allow passage of the fetus -lacerations of soft tissue (e.g. cervix, vagina, and perineum)

Monica AN24

-external fetal monitor that uses abdominally obtained electronic impulses to monitor FHA and UA -uses 5 electrodes placed on the woman's abdomen -information transmitted wirelessly, via Bluetooth no belt, repositioning

Fetal Scalp Blood Sampling

-for pH determination -obtaining a sample of fetal scalp blood through the dilated cervix -now seldom used in the US

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1 A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1 Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

During the vaginal examination of a laboring client, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 2 cm above the ischial spine. 1 cm above the ischial spine. at the level of the ischial spine. 1 cm below the ischial spine.

1 cm above the ischial spine. Rationale When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

The upper limits for the duration of normal second-stage labor in multiparous women:

1 hours with no regional anesthesia 2 hours with use of regional anesthesia

1. A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1, 2, 3, and 5 are correct. 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2. The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3. The client's age should also be noted before the physical assessment is begun. 4. The type of insurance the woman has is not relevant to the nurse. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth— should also be noted before a physical assessment is begun.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed pe riodically at the end of a contraction. 4. The fetal heart pattern should be as sessed every 1 hour during the latent phase of a low-risk labor. It is not stan dard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates pro gression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her la bor is more dependent on her level of pain and her preparation for labor than on the phases and/or stages of labor.

Which of the following actions would the nurse expect to perform immediately be fore a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1000 cc of Ringer's lactate. 3. Place woman in Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have woman empty her bladder.

1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should infuse Ringer's lac tate before the woman is given re gional anesthesia. 3. It is not necessary to place the woman in the Trendelenburg position. 4. The blood pressure will need to be mon itored every 5 minutes for 15 minutes af ter administration of the anesthesia, but not before. 5. The nurse should ask the woman to empty her bladder.

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. 1. Engage in sexual intercourse. 2. Ingest evening primrose oil. 3. Perform yoga exercises. 4. Eat raw spinach. 5. Massage the breast and nipples.

1, 2, and 5 are correct. 1. Nurse midwives sometimes recom mend that women at full term engage in sexual intercourse to stimulate labor. 2. Ingesting primrose oil is also some times recommended. Primrose oil is believed to help ripen the cervix. 3. Exercise should be encouraged through out pregnancy, but it is not used for induction. 4. Raw spinach is an excellent source of iron as well as a source of calcium and fiber. It is, however, not used for induction. 5. Nipple and breast massage is some times recommended to help induce labor.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? 1. Give the mother a back rub. 2. assist the woman with her breathing 3. Assess the fetal heart rate. 4. Check the blood pressure. 5. Regulate the intravenous rate

1,2 1. Give the mother a back rub. 2. assist the woman with her breathing

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Which of the following choices includes the correct order of the cardinal moves of labor? 1. descent 2. expulsion 3. extension 4. external rotation 5. internal rotation

1,5,3,4,2

Nitrazine Test

1. A Nitrazine test strip is used to detect presence of amniotic fluid in vaginal secretions. 2. Vaginal secretions have a pH of 4.5 to 5.5; they do not affect yellow color of Nitrazine strip or swab 3. Amniotic fluid has a pH of 7.0 to 7.5 and turn yellow Nitrazine strip or swab a blue color. 4. Interventions a. Place client in dorsal lithotomy position b. Touch test tape to fluid c. Asses test tape for a blue-green, blue-gray, or deep blue color, which indicates that membranes are probably ruptured. (positive or negative)

Vacuum extraction

1. A caplike suction device is applied to the fetal head to facilitate extraction. 2. Suction is used to assist in delivery of the fetal head. 3. Traction is applied during uterine contractions until descent of the fetal head is achieved. 4. The suction device should not be kept in place any longer than 25 minutes. 5. Monitor FHR every 5 minutes if external fetal monitoring is not used. 6. Assess infant at birth and throughout the postpartum period for signs of cerebral trauma. 7. Monitor for developing cephalhematoma. 8. Caput succedaneum is normal and resolves in 24 hours.

Fern Test

1. A microscopic slide test to determine the presence of amniotic fluid leakage. 2. With use of sterile technique, a specimen is obtained rom the external os of cervix and vaginal pool and examined on a slide under a microscope. 3 A fernlike pattern that results from the salts of amniotic fluid indicates the presence of amniotic flid 4. Interventions a. Place client in dorsal lithotomy position. b. Instruct client to cough; this causes fluid to leak from uterus if membranes are ruptured. (positive or negative)

5 Essential Components of Abnormal FHR Patterns that Need to be Evaluated

1. Baseline Rate 2. Baseline Variability 3. Accelerations 4. Decelerations 5. Changes or Trends over time

The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time? 1. Provide caring labor support. 2. Administer oxygen via tight fitting facemask. 3. Turn the woman on her side. 4. Apply the oxygen saturation electrode to the mother.

1. Because the variability is moderate (6 to 25 bpm wide), the nurse can conclude that the baby is well and that caring labor support is indicated.

when administering epidural

1. Bolus 1st 2. Vital signs 3. Platelet count greater than 100,000 4. EVERYONE wear a mask

What are the Tiers that Are Used to Classify Fetal Heart Rate?

1. Category I 2. Category II 3. Category III

On examination, it is noted that a full-term primipara in active labor is right occipi toanterior (ROA), 7 cm dilated, and 3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well. The pre senting part is 3 centimeters below the ischial spines.

2 Modes of EFM

1. External Mode- uses external transducers placed on the maternal abdomen to assess FHR and UA 2. Internal Mode- uses a spiral electrode applied to the fetal presenting part to assess the FHR and an intrauterine pressure catheter (IUPC) to assess UA and resting tone -can only be used when membranes have ruptured and cervix is sufficiently dilated [at least 2-3 cm] and presenting part is low enough to allow placement of spiral electrode)

A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Syrian woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman.

1. Muslim women, who are often from Arabic countries, are expected to keep their heads covered at all times.

Procedure for Intermittent Auscultation

1. Palpate maternal abdomen to determine fetal presentation 2. Apply ultrasonic gel to device if using Doppler ultrasound. Place listening device over area of maximal intensity and clarity of fetal heart sounds 3. Count maternal radial pulse while listening to FHR to differentiate it from fetal rate 4. Palpate abdomen for presence of absence of UA to count FHR between contractions 5. Count FHR for 30-60 seconds after a uterine contraction to identify auscultated baseline rate and changes in it 6. Auscultate FHR before, during, and after contrction to identify FHR during the contraction or as a response to the contraction and assess for increases or decreases in FHR keep fingertips placed over fundus before, during, and after contractions

Factors affecting the process of labor and birth: five P's

1. Passenger - fetus and placenta 2. Passageway - birth canal 3. Powers - contraction 4. Position - of the mother 5. Psychological response

What causes the fetal oxygen supply to decrease?

1. Reduction of blood flow through the maternal vessels as result of maternal hypertension (e.g. preeclampsia), hypotension (e.g. hemorrhage, epidural analgesia or anesthesia), or hypovolemia (caused by hemorrhage) 2. Reduction of oxygen content in maternal blood as a result of hemorrhage or severe anemia 3. Alterations in fetal circulation, occurring with compression of the umbilical cord, placental separation/abruption, or head compression 4. Reduction in blood flow to intervillous space in the placenta secondarty to uterine hypertonus or secondary to deterioration of the placental vasculature associated with post-term gestation or maternal disorders such as hypertension or diabetes mellitus

Causes of FHR Accelerations

1. Spontaneous fetal movement 2. Vaginal examination 3. Electrode application 4. Fetal scalp stimulation 5. Fetal reaction to external sounds 6. Breech position 7. Occiput posterior position 8. Uterine contractions 9. Fundal pressure 10. Abdominal palpation

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

1. Talking and laughing are characteris tic behaviors of the latent phase.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1. The cervix is thin.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful , when the client who makes which of the following statements ? 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucus plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. the client who says, "when i have felt cramping in my abdomen for 4 hours or more"

1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 4. The client who says, "If I ever notice a greenish discharge from my vagina."

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

1. The nurse would expect the woman to be 2 cm dilated.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA) 2. Left sacral posterior (LSP) 3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP)

1. The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior po sition (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal re gion, and the head is felt above her symphysis.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

1. The obstetric conjugate is the short est anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assess ments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1. The relationship between the deceler ations and the contractions will deter mine the type of deceleration pattern.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. The tracing is showing a normal fetal heart tracing. No intervention is needed.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

1. The woman should be helped into the fetal position.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. This is the correct response. A fetal heart rate of 152 is normal.

components of informed consent for general anesthesia

1. advantages disadvantages explained 2. woman must agree 3. consent without manipulation

hands-on approach (birth of head)

1. apply pressure against the rectum drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis; 2. apply upward pressure from the coccygeal region to extend the head during the actual birth, thereby protecting the musculature of the perineum; 3. assisting the mother with voluntary control of the bearing down efforts by coaching her to pant while letting uterine forces expel the fetus

3 phases of spontaneous birth

1. birth of head 2. birth of shoulders 3. birth of the body and extremities

Nonpharmacologic Pain Management

1. childbirth preparation methods 2. relaxing and breathing techniques 3. effleurage and counterpressure 4. touch and massage 5. application of heat and cold 6. acupressure and acupuncture 7. transcutaneous electrical nerve stimulation 8. water therapy ( hydrotherapy) 9. intradermal water block 10. aromatherapy 11. music 12. hypnosis 13. biofeedback

possibility of vaginal birth is determined

1. diameter at the plane of the pelvic inlet, midpelvis and outlet 2. axis of the birth canal

interview for admission for labor

1. time and onset of contractions and progress (frequency, duration, intensity) 2. location and character of discomfort from contractions 3. persistence of contractions despite changes in maternal position and activity 4. presence and character of vaginaldischarge or show 5. the status of amniotic membranes such as gush or seepage

fully dilated cervix

10 cm can no longer be palpated completely retracted mark end of the fist stage of labor

The nurse is monitoring the fetal heart rate (FHR) of a client in term labor. The FHR varies between 120 and 130 beats/minute over a 10-minute period. How does the nurse record the baseline? Record your answer using a whole number. beats/minute

125 Rationale After 10 minutes of tracing is observed, the approximate mean rate is rounded to the closest 5 beats/minute interval, which is 125 beats/minute.

The nurse notes that the fetus in a laboring patient is in brow presentation. What is the expected occipitomental diameter? 9.25 cm 9.5 cm 12.0 cm 13.5 cm

13.5 Rationale In a brow presentation, the presenting part is the mentum or chin. The occipitomental diameter is 13.5 cm at term, which is too large to permit the infant's head to enter the pelvis region of the mother. The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter. The smallest anteroposterior diameteris, the suboccipitobregmatic diameter, about 9.5 cm at term, is in a vertex presentation. In a sinciput presentation, the occipitofrontal diameter is about 12.0 cm at term, with moderate extension of the head.

The nurse is assessing the fetal heart rate in a pregnant client with diabetes during the first stage of labor. At what time intervals should the nurse perform FHR tracing? 5 minutes 60 minutes 15 minutes 30 minutes

15 minutes Rationale Diabetes is one of the risk factors in pregnancy. If any risk factors are present, the FHR tracing should be evaluated more frequently (every 15 minutes) in the first stage of labor and every 5 minutes in the second stage of labor. FHR should not be evaluated every 1 hour either in low-risk or high-risk clients. In low-risk clients the FHR tracing should be evaluated for every 30 minutes during the first stage of labor.

The nurse is assessing the uterine resting tone. Which resting tone is considered reassuring? Select all that apply. 18 mmHg with an IUPC 45 mmHg with an IUPC 350 Montevideo units with EFM 300 Montevideo units as measured internally Less than 810 Montevideo units as measured externally

18 mmHg with an IUPC The average uterine resting tone is expected to be less than 20 mmHg if measured with the IUPC. This would be a reassuring finding. 350 Montevideo units with EFM The average uterine resting tone is expected to be less than 400 Montevideo units by EFM. This would be reassuring finding.

course of labor consists of

1: regular progression of uterine contractions 2: effacement and progressive dilation of the cervix 3: progress in descent of the presenting part

4 stages of labor

1st stage: contractions and dilation and full effacement 2nd stage: pushing and delivery of the baby 3rd stage: delivery of the placenta 4th stage: initial postpartum recovery (~2hrs)

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2 Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

The upper limits for the duration of normal second-stage labor in nulliparous women:

2 hours with no regional anesthesia 3 hours with use of regional anesthesia

A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to make at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2. A wedge should be placed under one side of the woman.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Variable baseline of 140-150 with V-shaped decelerations to 120 unrelated to contractions. 2. Variable baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Flat baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Flat baseline of 140 to 142 with no obvious decelerations or accelerations.

2. Decelerations that mirror contrac tions are early decelerations. These are related to head compression and are expected during transition and second stage labor.

In addition to breathing with contractions, which of the following actions can help a woman in labor to work with the pain of the first stage of labor? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2. Effleurage is a light massage that can soothe the mother during labor.

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

2. Hypotension is a very common side effect of regional anesthesia.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

2. It is important to inquire about the pain level of all women in labor, but especially those from the Asian culture.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Once the cervix begins to dilate, a client is in true labor.

A G1P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesics. Which of the following medications would the nurse expect to be ordered with the analgesic medications? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen).

2. Phenergan is often used as an anal gesic potentiator.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA -1 station. 2. LSP -1 station. 3. LMP +1 station. 4. LSA +1 station.

2. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and but tocks at 1 station are 1 cm above the ischial spines.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

2. The blood pressure rises dramatically.

a pregnant woman is discussing possible delivery options with a labor nurse. which of the following client responses indicates that the woman understood the information. SATA 1. When the client states, "I am glad that deliveries can take place in a variety of places, including in a labor bed 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." 3. when the cleint states " I understand that if the fetus needs to turn during labor, i may end up delivering the baby on my hands and knees 4. When the client says, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

2. The nurse should provide additional information to this client. Many deliv eries are performed safely without stirrups.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2. The woman is showing expected signs of the active phase of labor.

Fetal adaptation to labor/ FHR

20 weeks 160 beats/ min as gestation progresses it slows down

maternal hypotension with decreased placental perfusion spinal anesthesia

20% decrease from preblock baseline fetal bradycardia absent of minimal FHR variability

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3 Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis

3 Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.

The nurse is caring for a nulliparous client who attended Lamaze childbirth educa tion classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

3, 4, and 5 are correct. 1. Hypnotic suggestion is usually not in cluded in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not in cluded in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education.

A client arrives at a birthing center in active labor. Her membranes are still intact, she is at -2 station and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. the need for frequent FHR monitoring to detect the presence of a prolapsed cord

3. Increased efficiency of contractions 5. the need for frequent FHR monitoring to detect the presence of a prolapsed cord

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. the spontaneous urge to push is initiated from perineal pressure

3. The cervix is dilated completely. 5. the spontaneous urge to push is initiated from perineal pressure

A woman is in active labor and is being monitored electronically. She has just re ceived Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3. Analgesics are CNS depressants. The variability of the fetal heart rate, therefore, will be decreased.

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3. During extension, the baby's head is birthed.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. It is essential to assess the fetal heart rate immediately after an amniotomy.

The nurse is caring for an Orthodox Jewish woman in labor. It would be appropri ate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet.

3. Observant Jewish women are ex pected to have their elbows covered at all times. A long-sleeved gown, there fore, should be provided for them.

The nurse is providing acupressure to provide pain relief to a woman in labor. Where is the best location for the acupressure to be applied? 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot 5. Below the medial epicondyle of the elbow.

3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis in or der to birth the baby.

The Lamaze childbirth educator is teaching a class of pregnant couples the breathing tech nique that is most appropriate during the second stage of labor. Which of the fol lowing techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

3. Open glottal pushing is used during stage 2 of labor.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3. Since the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

3. Since this is a normal finding, the nurse should continue to provide la bor support and encouragement.

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Where should the nurse place a fetoscope best to hear the fetal heart beat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

3. When a fetus is in the occiput poste rior position, mothers frequently complain of severe back pain.

A client is complaining of severe back labor. Which of the following nursing inter ventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Use a hydrotherapy tub.

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the fol lowing is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4 The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4 True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4 Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

active phase of labor

4-7 cm moderate to strong contractions regular q 3-5 min lasts 40-70 sec

active

4-7 cm dilation occurs during the active phase (Lasts about 3-6 hours) Contractions during the __ stage of the first stage of labor are... Moderate to strong More regular 3-5 min apart 40-70 seconds

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4. A fetus in a scapular presentation is in a horizontal lie.

A woman who states that she "thinks" she is in labor enters the labor suite. Whic of the following assessments will provide the nurse with the most valuable inform tion regarding the client's labor status? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. A vaginal examination will provide the nurse with the best information about the status of labor.

A labouring woman and two men enter the labor suite. One of the men states "we and our surrogate are here for our baby's delivery. Where should we go? " which of the following responses by the nurse would be appropriate? 1. congratulate the surrogate of the gift she is giving the gay couple 2. remind the men that labour and delivery experience is very stressful 3. remind the men that the women is the baby's mother 4. Ask the laboring woman whom she would like to be with her during labor

4. Ask the laboring woman whom she would like to be with her during labor

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Assess for signs of rectal pressure.

4. Assessing for rectal pressure is appropriate at this time.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effec tive at this point in the contraction.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

4. Intermittent auscultation should be performed for 1 full minute after con tractions end.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil.

4. Massaging of the perineum with min eral oil does help to reduce perineal tearing.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

4. Moderate variability is indicative of fetal health.

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4. Most women find slow chest breath ing effective during the latent phase.

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

4. The baby's head is almost crowning.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head seen at the vaginal introitus. The nurse concludes that the client is now 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. The cervix is fully dilated and fully ef faced and the baby is low enough to be seen through the vaginal introitus.

A nurse describes a client's contraction pattern as: frequency every 3 min and dura tion 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman in dicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4. This client is exhibiting clear signs of true labor. Not only are the contrac tions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 gm/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

4. This fetal pH value is within normal limits.

Which cervical dilatation will the nurse expect to observe when assessing a patient in active labor? 5 cm 3 cm 0 cm 10 cm

5 cm The cervix dilates more rapidly as the woman enters the active phase, between approximately 4 to 6 cm.

clinical significance of variable decelerations

50% of all labors transient and correctable

How long might the typical latent phase of labor last, and how much cervical dilatation is expected? 7 hours, 4 cm of cervical dilatation 9 hours, 6 cm of cervical dilatation 30 min, 10 cm of cervical dilatation 12-24 hours, 1 cm of cervical dilatation

7 hours, 4 cm of cervical dilatation The latent, or early, phase lasts from the beginning of labor until about 3 to 5 cm of cervical dilatation.

During the transition phase, cervical dilatation is expected to be what? 8 to 10 cm 4 to 8 cm 0 to 10 cm 0 to 3 or 4 cm

8 to 10 cm Transition is used to describe the intense contractions of fetal descent and final cervical dilatation, about 7 or 8 cm to complete.

Transition phase of labor

8-10 cm strong to very strong contractions q 2-3 min lasts 45-90 sec

transition

8-10 cm dilation occurs during the transition phase (Lasts about 20-40 minutes) Contractions during the __ stage of the first stage of labor are... Strong to very strong Regular 2-3 min apart 45-90 seconds

The physician writes the following order for a newly admitted client in labor: Begin a 1000 cc IV of D5 1/2 NS at 150 cc/hr. The IV tubing states that the drop factor is 10 gtt/cc. Calculate the drip rate. _______ gtt/min

87. 25 gtt/min

The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV stat for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? _____ mL

88. 0.25 mL

Which characteristics of effacement and dilatation describe the laboring woman who is closest to delivery? 3 cm dilated, 40% effaced 5 cm dilated, 60% effaced 7 cm dilatation, 80% effaced 9 cm dilatation, 100% effaced

9 cm dilatation, 100% effaced Transition may be used to describe the intense contractions of fetal descent and final cervical dilatation, about 7 or 8 cm to complete.

fetal Bradycardia

A baseline FHR of fewer than 110 bpm for 10 minutes or longer -Baseline bradycardia alone is not specifically related to fetal oxygenation -The clinical significance of bradycardia depends on the underlying cause and the accompanying FHR patterns including variability, accelerations, or decelerations

siblings

A child younger than2 years of age shows little to no interest in pregnancy and labor

Which pregnant client is likely to have a cesarean delivery? A client with the fetus in a transverse lie A client with the fetus in a cephalic presentation A client with the fetal biparietal diameter of 9.25 cm at term A client in whom the presenting part is 4 cm below the spines

A client with the fetus in a transverse lie A transverse lie indicates that the long axis of the fetus is at a right angle, diagonal to the long axis of the mother. As a result, a vaginal birth is not possible and the client will need a cesarean delivery. A cephalic presentation indicates that the fetal head will lead through the birth canal during labor. This presentation facilitates vaginal delivery. A fetal biparietal diameter of 9.25 cm indicates normal head growth, which can be easily delivered vaginally. If the presenting part is 4 cm below the spines, it indicates that birth is imminent. The part is not an indicator of the type of birth.

Group B Streptococcus (GBS)

A common bacterium found in the vagina and rectum of healthy women. However, an infant infected with GBS can develop septicimena, pneumonia, or meningitis. (Screened on admission to determine if the woman must be given antibiotics during labor)

Which sign does not precede the onset of labor? A return of urinary frequency as a result of increased bladder pressure Persistent low backache from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions A decline in energy, as the body stores up for labor

A decline in energy, as the body stores up for labor A surge of energy is a phenomenon that is common in the days preceding labor. After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Prior to the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength; bloody show may be passed.

With regard to spinal and epidural (block) anesthesia, nurses should know that: This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. A high incidence of postbirth headache is seen with spinal blocks. Epidural blocks allow the woman to move freely. Spinal and epidural blocks are never used together

A high incidence of postbirth headache is seen with spinal blocks. The headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

With regard to spinal and epidural (block) anesthesia, nurses should know what? This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births A high incidence of postpartum headache is seen with spinal blocks Epidural blocks allow the woman to move freely Spinal and epidural blocks are never used together

A high incidence of postpartum headache is seen with spinal blocks Rationale Headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

The nurse has performed vibroacoustic stimulation and determines that the fetal heart rate has increased by 15 beats/min from the baseline within 15 seconds. Which condition does this acceleration indicate? Mixed acidemia in the fetus Signs of respiratory acidemia A normal pH level in the fetus Elevated pCO 2 level in the fetus

A normal pH level in the fetus Rationale FHR acceleration by about 15 beats/min in 15 seconds on vibroacoustic stimulation indicates a normal blood pH of the fetus. A decreased pH and elevated carbon dioxide pressure indicate respiratory acidemia. Therefore FHR acceleration is not indicative of either respiratory acidemia or mixed acidemia in the fetus. The umbilical cord acid-base method involves the determination of both the carbon dioxide pressure and oxygen pressure of the fetus.

Sinusoidal Fetal Heart Rate Pattern

A regular, smooth, undulating wavelength pattern -not included in definition of FHR variability -classically occurs with severe fetal anemia

Administering an opioid antagonist to a women who is opioid dependent will result in the opioid dependent will result in the opioid abstinence syndrome. The nurse would recognize which clinical manifestations as evidence that this syndrome is occurring? (Circle all that apply.) A) Yawning B) Coughing C) Piloerection D) Anorexia E) Dry skin, eyes, and nose F) Miosis

A) Yawning C) Piloerection D) Anorexia

Lightening or dropping

AKA Engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery; most noticeable in first pregnancies

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand? a. Client is considered to be in active labor when she arrives at the facility with contractions. b. Client can have only her male partner or predesignated doula with her at assessment. c. Children are not allowed on the labor unit. d. Non-English speaking client must bring someone to translate.

ANS: A According to the Emergency Medical Treatment and Active Labor Act (EMTALA), a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman may have anyone she wishes present for her support. An interpreter must be provided by the hospital, either in person or by a telephonic service. Siblings of the new infant may be allowed at the delivery, depending on hospital policy and adequate preparation and supervision.

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory? a. Massage the woman's back. b. Change the woman's position. c. Give the prescribed medication. d. Encourage the woman to rest between contractions.

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques, such as massage or stroking, music, focal points, and imagery, reduce or completely block the capacity of the nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, administering pain medication, and resting between contractions do not reduce or block the capacity of the nerve pathways to transmit pain using the gate-control theory.

Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion? a. Variable decelerations b. Late decelerations c. Fetal bradycardia d. Fetal tachycardia

ANS: A Amnioinfusion is used during labor to either dilute meconium-stained amniotic fluid or supplement the amount of amniotic fluid to reduce the severity of variable FHR decelerations caused by cord compression. Late decelerations are unresponsive to amnioinfusion. Amnioinfusion is not appropriate for the treatment of fetal bradycardia and has no bearing on fetal tachycardia.

A client is experiencing back labor and complains of intense pain in her lower back. Which measure would best support this woman in labor? a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques c. Effleurage d. Conscious relaxation or guided imagery

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

The nurse expects which maternal cardiovascular finding during labor? a. Increased cardiac output b. Decreased pulse rate c. Decreased white blood cell (WBC) count d. Decreased blood pressure

ANS: A During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system, which increases cardiac output by approximately 10% to 15% during the first stage of labor and by approximately 30% to 50% in the second stage of labor. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by approximately 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: A Early decelerations are the fetus' response to fetal head compression; these are considered benign, and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur? a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration

ANS: A Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the administration of magnesium sulfate will each more likely result in fetal bradycardia, not tachycardia.

As the United States and Canada continue to become more culturally diverse, recognizing a wide range of varying cultural beliefs and practices is increasingly important for the nursing staff. A client is from which country if she requests to have the baby's father in attendance? a. Mexico b. China c. Iran d. India

ANS: A Hispanic women routinely have fathers and female relatives in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well. In China, fathers are usually not present. The side-lying position is preferred for labor and birth because it is believed that this will reduce trauma to the infant. In China, the client has a stoic response to pain. In Iran, the father will not be present. Female support persons and female health care providers are preferred. For many, a male caregiver is unacceptable. In India, the father is usually not present, but female relatives are usually in attendance. Natural childbirth methods are preferred.

Which presentation is accurately described in terms of both the resenting part and the frequency of occurrence? a. Cephalic: occiput, at least 96% b. Breech: sacrum, 10% to 15% c. Shoulder: scapula, 10% to 15% d. Cephalic: cranial, 80% to 85%

ANS: A In cephalic presentations (head first), the presenting part is the occiput; this presentation occurs in 96% of births. In a breech birth, the sacrum emerges first; this presentation occurs in approximately 3% of births. In shoulder presentations, the scapula emerges first; this presentation occurs in only 1% of births. In a cephalic presentation, the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births.

Which component of the physical examination are Leopold's maneuvers unable to determine? a. Gender of the fetus b. Number of fetuses c. Fetal lie and attitude d. Degree of the presenting part's descent into the pelvis

ANS: A Leopold's maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus cannot be determined by performing Leopold's maneuvers.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. What is the nurse's assessment of the situation? a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.

ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, then the nurse would expect to find the uterus boggy and displaced to the side.

Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation? a. Ritgen maneuver b. Fundal pressure c. Lithotomy position d. De Lee apparatus

ANS: A The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is used to suction fluid from the infant's mouth.

What is the correct placement of the tocotransducer for effective EFM? a. Over the uterine fundus b. On the fetal scalp c. Inside the uterus d. Over the mother's lower abdomen

ANS: A The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.

The client has delivered by urgent caesarean birth for fetal compromise. Umbilical cord gases were obtained for acid-base determination. The pH is 6.9, partial pressure of carbon dioxide (PCO2) is elevated, and the base deficit is 11 mmol/L. What type of acidemia is displayed by the infant? a. Respiratory b. Metabolic c. Mixed d. Turbulent

ANS: A These findings are evidence of respiratory acidemia. Metabolic acidemia is expressed by a pH <7.20, normal carbon dioxide pressure, and a base excess of 12 mmol/L. Mixed acidemia is evidenced by a pH <7.20, elevated carbon dioxide pressure, and a base excess of 12 mmol/L. There is no such finding as turbulent acidemia.

A nurse caring for a woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign? a. Periodic fetal sleep state b. Extreme prematurity c. Fetal hypoxemia d. Preexisting neurologic injury

ANS: A When the fetus is temporarily in a sleep state, minimal variability is present. Periodic fetal sleep states usually last no longer than 30 minutes. A woman in labor with extreme prematurity may display a FHR pattern of minimal or absent variability. Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. Congenital anomalies or a preexisting neurologic injury may also result in absent or minimal variability. Other possible causes might be central nervous system (CNS) depressant medications, narcotics, or general anesthesia.

The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication? a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension

ANS: A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.

In assessing the immediate condition of the newborn after birth, a sample of cord blood may be a useful adjunct to the Apgar score. Cord blood is then tested for pH, carbon dioxide, oxygen, and base deficit or excess. Which clinical situation warrants this additional testing? (Select all that apply.) a. Low 5-minute Apgar score b. Intrauterine growth restriction (IUGR) c. Maternal thyroid disease d. Intrapartum fever e. Vacuum extraction

ANS: A, B, C, D The American College of Obstetricians and Gynecologists (ACOG) suggests obtaining cord blood values in all of these clinical situations except for vacuum extractions deliveries. Cord blood gases should also be performed for multifetal pregnancies or abnormal FHR tracings. Samples can be drawn from both the umbilical artery and the umbilical vein. Results may indicate that fetal compromise has occurred.

Because of its size and rigidity, the fetal head has a major effect on the birth process. Which bones comprise the structure of the fetal skull? (Select all that apply.) a. Parietal b. Temporal c. Fontanel d. Occipital e. Femoral

ANS: A, B, D The fetal skull has two parietal bones, two temporal bones, an occipital bone, and a frontal bone. The fontanels are membrane-filled spaces.

A woman has requested an epidural block for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. Before the initiation of the epidural, the woman should be informed regarding the disadvantages of an epidural block. Which concerns should the nurse share with this client? (Select all that apply.) a. Ability to move freely is limited. b. Orthostatic hypotension and dizziness may occur. c. Gastric emptying is not delayed. d. Higher body temperature may occur. e. Blood loss is not excessive.

ANS: A, B, D The woman's ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (IV lines and electronic fetal monitoring [EFM]). Significant disadvantages of an epidural block include the occurrence of orthostatic hypotension, dizziness, sedation, and leg weakness. Women who receive an epidural block have a higher body temperature (38° C or higher), especially when labor lasts longer than 12 hours, and may result in an unnecessary neonatal workup for sepsis. An advantage of an epidural block is that blood loss is not excessive. Other advantages include the following: the woman remains alert and able to participate, good relaxation is achieved, airway reflexes remain intact, and only partial motor paralysis develops.

Which factors influence cervical dilation? (Select all that apply.) a. Strong uterine contractions b. Force of the presenting fetal part against the cervix c. Size of the woman d. Pressure applied by the amniotic sac e. Scarring of the cervix

ANS: A, B, D, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can also promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size or the size of the woman does not affect cervical dilation.

Which changes take place in the woman's reproductive system, days or even weeks before the commencement of labor? (Select all that apply.) a. Lightening b. Exhaustion c. Bloody show d. Rupture of membranes e. Decreased fetal movement

ANS: A, C, D Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor.

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Which signs would indicate opioid or narcotic withdrawal in the mother? (Select all that apply.) a. Yawning, runny nose b. Increase in appetite c. Chills or hot flashes d. Constipation e. Irritability, restlessness

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. Assessing both the mother and the newborn and planning the care accordingly are important steps for the nurse to take.

Which statement is the best rationale for assessing the maternal vital signs between uterine contractions? a. During a contraction, assessing the fetal heart rate is the priority. b. Maternal circulating blood volume temporarily increases during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.

ANS: B During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which, in turn, temporarily increases blood pressure and slows the pulse. Monitoring fetal responses to the contractions is important; however, this question concerns the maternal vital signs. Maternal blood flow is increased during a contraction. Vital signs are altered by contractions but are considered accurate for that period.

A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. The nurse applies the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. What is the nurse's best response? a. "Don't worry about that machine; that's my job." b. "The baby's heart rate will fluctuate in response to what is happening during labor." c. "The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are." d. "Your physician will explain all of that later."

ANS: B Explaining what indicates a normal FHR teaches the partner about fetal monitoring and provides support and information to alleviate his fears. Telling the partner not to worry discredits his feelings and does not provide the teaching he is requesting. Telling the partner that the graph indicates how strong the contractions are provides inaccurate information and does not address the partner's concerns about the FHR. The EFM graphs the frequency and duration of the contractions, not their intensity. Nurses should take every opportunity to provide teaching to the client and her family, especially when information is requested.

What is the primary difference between the labor of a nullipara and that of a multipara? a. Amount of cervical dilation b. Total duration of labor c. Level of pain experienced d. Sequence of labor mechanisms

ANS: B In a first-time pregnancy, the descent is usually slow but steady; in subsequent pregnancies, the descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors.

Which characteristic correctly matches the type of deceleration with its likely cause? a. Early deceleration—umbilical cord compression b. Late deceleration—uteroplacental insufficiency c. Variable deceleration—head compression d. Prolonged deceleration—unknown cause

ANS: B Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

What is the correct term describing the slight overlapping of cranial bones or shaping of the fetal head during labor? a. Lightening b. Molding c. Ferguson reflex d. Valsalva maneuver

ANS: B Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother's sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after the stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.

What is the role of the nurse as it applies to informed consent? a. Inform the client about the procedure, and ask her to sign the consent form. b. Act as a client advocate, and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form.

ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse's responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state's guidelines, the woman's husband or another hospital health care employee may sign as a witness.

A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination? a. "The two medications, together, reduce complications." b. "Sedatives enhance the effect of the pain medication." c. "The two medications work better together, enabling you to sleep until you have the baby." d. "This is what your physician has ordered for you."

ANS: B Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause two drugs to work together more effectively, but it does not ensure zero maternal or fetal complications. Sedation may be a related effect of some ataractic drugs; however, sedation is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. Although the physician may have ordered the medication, "This is what your physician has ordered for you" is not an acceptable comment for the nurse to make.

Which description of the phases of the first stage of labor is most accurate? a. Latent: mild, regular contractions; no dilation; bloody show b. Active: moderate, regular contractions; 4 to 7 cm dilation c. Lull: no contractions; dilation stable d. Transition: very strong but irregular contractions; 8 to 10 cm dilation

ANS: B The active phase is characterized by moderate and regular contractions, 4 to 7 cm dilation, and duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions, dilation up to 3 cm, brownish-to-pale pink mucus, and duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong and regular contractions, 8 to 10 cm dilation, and duration of 20 to 40 minutes.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. Which description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

ANS: B The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions; dilation up to 3 cm; brownish-to-pale pink mucus, and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong- to-very strong and regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes.

A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care? a. Tell the client to relax and that it won't hurt much. b. Limit the number of procedures that invade her body. c. Reassure the client that, as the nurse, you know what is best. d. Allow unlimited care providers to be with the client.

ANS: B The number of invasive procedures such as vaginal examinations, internal monitoring, and IV therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the client's recalling the phrases of her abuser (i.e., "Relax, this won't hurt" or "Just open your legs"). The woman's sense of control should be maintained at all times. The nurse should explain procedures at the client's pace and wait for permission to proceed. Protecting the client's environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe.

What is the most likely cause for variable FHR decelerations? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia

ANS: B Variable FHR decelerations can occur at any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia continues.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could the nurse use to increase the client's blood pressure? (Select all that apply.) a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase IV fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until the woman is stable. Placing the client in a supine position causes venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

Which FHR decelerations would require the nurse to change the maternal position? (Select all that apply.) a. Early decelerations b. Late decelerations c. Variable decelerations d. Moderate decelerations e. Prolonged decelerations

ANS: B, C, E Early decelerations (and accelerations) do not generally need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral). Variable decelerations also require a maternal position change (side to side). Moderate decelerations are not an accepted category. Prolonged decelerations are late or variable decelerations that last for a prolonged period (longer than 2 minutes) and require intervention.

A tiered system of categorizing FHR has been recommended by professional organizations. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. What is the correct nomenclature for these categories? (Select all that apply.) a. Reassuring b. Category I c. Category II d. Nonreassuring e. Category III

ANS: B, C, E The three-tiered system of FHR tracings include category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate and includes tracings that do not meet category I or III criteria. Category III tracings are abnormal and require immediate intervention.

According to the National Institute of Child Health and Human Development (NICHD) Three-Tier System of FHR Classification, category III tracings include all FHR tracings not categorized as category I or II. Which characteristics of the FHR belong in category III? (Select all that apply.) a. Baseline rate of 110 to 160 beats per minute b. Tachycardia c. Absent baseline variability not accompanied by recurrent decelerations d. Variable decelerations with other characteristics such as shoulders or overshoots e. Absent baseline variability with recurrent variable decelerations f. Bradycardia

ANS: B, D, E, F Tachycardia, variable decelerations with other characteristics, absent baseline variability with recurrent variable decelerations, and bradycardia are characteristics that are considered nonreassuring or abnormal and belong in category III. A FHR of 110 to 160 beats per minute is considered normal and belongs in category I. Absent baseline variability not accompanied by recurrent decelerations is a category II characteristic.

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. Fetal head is felt at 0 station during vaginal examination. b. Bloody mucous discharge increases. c. Vulva bulges and encircles the fetal head. d. Membranes rupture during a contraction.

ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. ROM can occur at any time during the labor process and does not indicate an imminent birth.

A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone (Narcan), can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl (Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.

The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of the fetal body parts to one another? a. Lie b. Presentation c. Attitude d. Position

ANS: C Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother's pelvis.

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. Fetal head is felt at 0 station during the vaginal examination. b. Bloody mucous discharge increases. c. Vulva bulges and encircles the fetal head. d. Membranes rupture during a contraction.

ANS: C During the active pushing (descent) phase, the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge, encircling the fetal head. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

Which clinical finding indicates that the client has reached the second stage of labor? a. Amniotic membranes rupture. b. Cervix cannot be felt during a vaginal examination. c. Woman experiences a strong urge to bear down. d. Presenting part of the fetus is below the ischial spines.

ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. The ROM has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting fetal part is below the level of the ischial spines. This urge can occur during the first stage of labor, as early as with 5 cm dilation.

In which clinical situation would the nurse most likely anticipate a fetal bradycardia? a. Intraamniotic infection b. Fetal anemia c. Prolonged umbilical cord compression d. Tocolytic treatment using terbutaline

ANS: C Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

When assessing the fetus using Leopold's maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline. What is the position of the fetus? a. ROA b. LSP c. RSA d. LOA

ANS: C Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.

What is the primary rationale for the thorough drying of the infant immediately after birth? a. Stimulates crying and lung expansion b. Removes maternal blood from the skin surface c. Reduces heat loss from evaporation d. Increases blood supply to the hands and feet

ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Although rubbing the infant stimulates crying, it is not the main reason for drying the infant. This process does not remove all the maternal blood.

The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate? a. Early FHR decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

The nurse observes a sudden increase in variability on the ERM tracing. Which class of medications may cause this finding? a. Narcotics b. Barbiturates c. Methamphetamines d. Tranquilizers

ANS: C Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; whereas methamphetamines may cause increased variability.

Where is the point of maximal intensity (PMI) of the FHR located? a. Usually directly over the fetal abdomen b. In a vertex position, heard above the mother's umbilicus c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and internally rotates d. In a breech position, heard below the mother's umbilicus

ANS: C Nurses should be prepared for the shift. The PMI of the FHR is usually directly over the fetal back. In a vertex position, the PMI of the FHR is heard below the mother's umbilicus. In a breech position, it is heard above the mother's umbilicus.

Which statement by the client would lead the nurse to believe that labor has been established? a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

ANS: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not the indicator of true labor.

A woman in labor has just received an epidural block. What is the most important nursing intervention at this time? a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is for the nurse to monitor the maternal blood pressure frequently for signs of hypotension. IV fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse also observes for signs of fetal bradycardia and monitors for signs of maternal tachycardia, secondary to hypotension.

A labor and delivery nurse should be cognizant of which information regarding how the fetus moves through the birth canal? a. Fetal attitude describes the angle at which the fetus exits the uterus. b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother. c. Normal attitude of the fetus is called general flexion. d. Transverse lie is preferred for vaginal birth.

ANS: C The normal attitude of the fetus is called general flexion. The fetal attitude is the relationship of the fetal body parts to each one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie, the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. The nurse reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for this woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia and anesthesia. Typically, epidural analgesia and anesthesia are used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit levels are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.

Nurses should be cognizant of what regarding the mechanism of labor? a. Seven critical movements must progress in a more or less orderly sequence. b. Asynclitism is sometimes achieved by means of the Leopold's maneuver. c. Effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head. d. At birth, the baby is said to achieve "restitution"; that is, a return to the C-shape of the womb.

ANS: C The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor simultaneously occur in combinations, not in precise sequences. Asynclitism is the deflection of the baby's head; the Leopold's maneuver is a means of judging descent by palpating the mother's abdomen. Restitution is the rotation of the baby's head after the infant is born.

What is a distinct advantage of external EFM? a. The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the FHR. b. The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions. c. The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor. d. Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C The tocotransducer is valuable for measuring uterine activity during the first stage of labor and is especially true when the membranes are intact. Short-term variability and beat-to-beat changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of uterine contractions. The transducer must be repositioned when the woman or the fetus changes position.

A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin (Pitocin). She presses her call light, and asks for her nurse right away, stating "I'm bleeding a lot." What is the most likely cause of postpartum hemorrhaging in this client? a. Retained placental fragments b. Unrepaired vaginal lacerations c. Uterine atony d. Puerperal infection

ANS: C This woman gave birth to a macrosomic infant after oxytocin augmentation. Combined with these risk factors, uterine atony is the most likely cause of bleeding 4 hours after delivery. Although retained placental fragments may cause postpartum hemorrhaging, it is typically detected within the first hour after delivery of the placenta and is not the most likely cause of the hemorrhaging in this woman. Although unrepaired vaginal lacerations may also cause bleeding, it typically occurs in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding that is, however, typically detected 24 hours postpartum.

Which adaptation of the maternal-fetal exchange of oxygen occurs in response to uterine contraction? a. The maternal-fetal exchange of oxygen and waste products continues except when placental functions are reduced. b. This maternal-fetal exchange increases as the blood pressure decreases. c. It diminishes as the spiral arteries are compressed. d. This exchange of oxygen and waste products is not significantly affected by contractions.

ANS: C Uterine contractions during labor tend to decrease circulation through the spiral electrodes and subsequent perfusion through the intervillous space. The maternal blood supply to the placenta gradually stops with contractions. The exchange of oxygen and waste products decreases. The exchange of oxygen and waste products is affected by contractions.

The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations? a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid

ANS: C Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. Umbilical cord compression results in variable FHR decelerations. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

The baseline FHR is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the client's most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (Select all that apply.) a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension

ANS: C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure, and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression, which may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when a short cord, a knot in the cord, or a prolapsed cord is present.

Which basic type of pelvis includes the correct description and percentage of occurrence in women? a. Gynecoid: classic female pelvis; heart shaped; 75% b. Android: resembling the male pelvis; wide oval; 15% c. Anthropoid: resembling the pelvis of the ape; narrow; 10% d. Platypelloid: flattened, wide, and shallow pelvis; 3%

ANS: D A platypelloid pelvis is flattened, wide, and shallow; approximately 3% of women have this shape. The gynecoid pelvis is the classic female shape, slightly ovoid and rounded; approximately 50% of women have this shape. An android or malelike pelvis is heart shaped; approximately 23% of women have this shape. An anthropoid or apelike pelvis is oval and wide; approximately 24% of women have this shape.

When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain? a. Tell the woman to stay home until her membranes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to describe why she believes she is in labor.

ANS: D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data. The initial nursing activity should be to gather data about the woman's status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time? a. Notify the woman's health care provider. b. Administer the prescribed narcotic analgesic. c. Assure her that her labor will be over soon. d. Assist her with simple breathing and relaxation instructions.

ANS: D By reducing tension and stress, both focusing and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful. The nurse can independently perform many functions in labor and birth, such as teaching and support. Pain medication may be an option for this client. However, the initial response of the nurse should include teaching the client about her options. The length of labor varies among individuals, but the first stage of labor is the longest. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.

An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, "My contractions are so strong, I don't know what to do." Before making a plan of care, what should the nurse's first action be? a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual.

ANS: D Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. This scenario includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.

Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth. Which change in fetal physiologic activity is not part of this process? a. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. b. Fetal partial pressure of oxygen (PO2) decreases. c. Fetal partial pressure of carbon dioxide in arterial blood (PaCO2) increases. d. Fetal respiratory movements increase during labor.

ANS: D Fetal respiratory movements actually decrease during labor. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. Fetal PO2 decreases, and fetal PaCO2 increases.

What physiologic change occurs as the result of increasing the infusion rate of nonadditive IV fluids? a. Maintaining normal maternal temperature b. Preventing normal maternal hypoglycemia c. Increasing the oxygen-carrying capacity of the maternal blood d. Expanding maternal blood volume

ANS: D Filling the mother's vascular system increases the amount of blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions experience more pain. d. Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

Which FHR finding is the most concerning to the nurse who is providing care to a laboring client? a. Accelerations with fetal movement b. Early decelerations c. Average FHR of 126 beats per minute d. Late decelerations

ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR finding of 126 beats per minute is normal and not a concern.

The nurse is using intermittent auscultation (IA) to locate the fetal heartbeat. Which statement regarding this method of surveillance is accurate? a. The nurse can be expected to cover only two or three clients when IA is the primary method of fetal assessment. b. The best course is to use the descriptive terms associated with EFM when documenting results. c. If the heartbeat cannot be immediately found, then a shift must be made to EFM. d. Ultrasound can be used to find the FHR and to reassure the mother if the initial difficulty is a factor.

ANS: D Locating fetal heartbeats often takes time. Mothers can be verbally reassured and reassured by viewing the ultrasound pictures if that device is used to help locate the heartbeat. When used as the primary method of fetal assessment, IA requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.

The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with which condition? a. Hypotension b. Cord compression c. Maternal drug use d. Hypoxemia

ANS: D Nonreassuring FHR patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Variable FHR decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles. When is it appropriate to instruct the client to use this maneuver? a. During the second stage to enhance the movement of the fetus b. During the third stage to help expel the placenta c. During the fourth stage to expel blood clots d. Not at all

ANS: D The client should not be instructed to use this maneuver. This process stimulates the parasympathetic division of the autonomic nervous system and produces a vagal response (decrease in heart rate and blood pressure.) An alternative method includes instructing the client to perform open-mouth and open-glottis breathing and pushing

Which statement regarding the care of a client in labor is correct and important to the nurse as he or she formulates the plan of care? a. The woman's blood pressure will increase during contractions and fall back to prelabor normal levels between contractions. b. The use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c. Having the woman point her toes will reduce leg cramps. d. Endogenous endorphins released during labor will raise the woman's pain threshold and produce sedation.

ANS: D The endogenous endorphins released during labor will raise the woman's pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure levels increase during contractions but remain somewhat elevated between them. The use of the Valsalva maneuver is discouraged during the second stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

In which situation would the nurse be called on to stimulate the fetal scalp? a. As part of fetal scalp blood sampling b. In response to tocolysis c. In preparation for fetal oxygen saturation monitoring d. To elicit an acceleration in the FHR

ANS: D The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor.

The nurse is evaluating the EFM tracing of the client who is in active labor. Suddenly, the FHR drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next? a. Call for help. b. Insert a Foley catheter. c. Start administering Pitocin. d. Immediately notify the care provider.

ANS: D To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluids, and provide oxygen. If oxytocin is infusing, then it should be discontinued. If the FHR does not resolve, then the primary care provider should be immediately notified. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, then a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. The administration of Pitocin may place additional stress on the fetus.

Which characteristic of a uterine contraction is not routinely documented? a. Frequency: how often contractions occur b. Intensity: strength of the contraction at its peak c. Resting tone: tension in the uterine muscle d. Appearance: shape and height

ANS: D Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not routinely charted.

Leopold Maneuvers

Abdominal palpations used to determine the fetal presentation, lie, position and engagement; supine position place both cupped hands over the fundus and palpate the determine fetal position;

Causes of Absent or Minimal Variability in Heart Rate

Absent Variability- amplitude range undetectable Minimal Variability- amplitude range detectable (< or equal to 5 bpm) Fetal hypoxemia, metabolic acidemia, congenital anomalies, preexisting neurologic injury, CNS depressants medications including analgesics and narcotics, can occur with tachycardia, prematurity, or when fetus is temporarily in a sleep state

Category III Fetal Heart Rate Classification

Absent baseline variability and any of the following: -recurrent late decelerations -recurrent variable decelerations -bradycardia -sinusoidal pattern

Match the infant condition to the correct interpretations.

Absent heart rate; no spontaneous respiration; minimal flexion; no response to suction; blue hands and feet Severe distress Heart rate 90 bpm; weak cry; flexed body posture; no response to suction; blue hands and feet Moderate difficulty Heart rate 110 bpm; lusty cry; minimal flexion of extremities; prompt response to gentle slap on sole; pink skin Little-to-no distress

When assessing a fetal heart rate, which qualities represent a reassuring heart rate pattern to the nurse? Select all that apply. Acceleration Late deceleration Moderate variability Baseline FHR with a rate of 100 Baseline FHR with a rate of 110

Acceleration Acceleration is a quality of reassuring FHR. It reflects a fetus that has a responsive central nervous system and is not in acidosis. Moderate variability Moderate variability is a reassuring quality of FHR when in the 6-25 bmp range. Baseline FHR with a rate of 110 A baseline FHR from 110-160 is a reassuring quality.

Match the signs of reassuring FHR patterns with their descriptions.

Accelerations Peaking at least 15 bpm Normal baseline FHR FHR of 130 bpm Moderate variability 6-25 bpm

HIPAA

According to __, the woman must give permission for other individuals to be involved in the exchange of information regarding her care.

Delivery

Actual event of birth

Pattern-Paced Breathing (Pant-Blow)

After a certain number of breaths (modified-paced breathing) the woman exhales with a slight blow and then begins modified-paced breathing again.

At birth, the newborn is covered with blood, amniotic fluid, vernix, and other body substances. When can the nurse engage in infant contact without gloves and other personal protective equipment? After the first bath Immediately following expulsion After an APGAR score of 8 or higher When handing the infant to the mother

After the first bath To avoid contact with infectious secretions, personnel involved in infant contact should wear gloves and other protective equipment until after the first bath.

restitution and external rotation

After the head is born, it rotates to the position it occupied as it entered the pelvic inlet (restitution) reallignment of fetal head with the back and shoulders anterior shoulder descend first, it reached midline, rotates, delivered from under pubic arch

Spontaneous rupture of membranes (SROM)

Amniotic sac ruptures from intense contraction, no outside action is used

Marked Variability

Amplitude range > or equal to 25 bpm -significance unknown

Under which circumstances should a vaginal examination be performed by the nurse? An admission to the hospital at the start of labor When accelerations of the fetal heart rate (FHR) are noted On maternal perception of perineal pressure or the urge to bear down When membranes rupture When bright, red bleeding is observed

An admission to the hospital at the start of labor On maternal perception of perineal pressure or the urge to bear down When membranes rupture Rationale Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM) a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

The midwife has requested an amnioinfusion. Which internal uterine catheter should the nurse prepare? An intrauterine pressure catheter An amnioinfusion intravenous catheter A fluid-filled intrauterine pressure catheter An extra lumen attached to the fetal scalp electrode for amnioinfusion

An intrauterine pressure catheter The nurse should prepare a solid intrauterine pressure catheter, which specifically has an extra lumen for amnioinfusion.

A 17-year-old primigravida is admitted in early labor. Her cervix is 2 to 3 cm dilated and 100% effaced. The fetus is cephalic, and the presenting part is at -1 station. Her membranes are intact. The patient is holding her boyfriend's hand tightly and breathing rapidly with each contraction. She tells the nurse in a shaky voice, "I'm so nervous. I've never been in a hospital before. I don't know anything about labor or if I can do this." What is an appropriate nursing diagnosis for this patient? Potential for injury related to physical assault by support person Inappropriate coping mechanisms related to adolescence Inadequate support related to lack of family support Anxiety related to unfamiliar environment and lack of birth preparation

Anxiety related to unfamiliar environment and lack of birth preparation

The nurse is assisting the primary health care provider during a client's vaginal delivery. Which nursing intervention is performed to reduce the extent of vaginal or perineal lacerations? Placing clean material under the client's buttocks Touching the client's vaginal area to promote birth Applying gentle pressure toward the client's vagina Allowing rapid birth of the fetal head

Applying gentle pressure toward the client's vagina Rationale During vaginal delivery, the client may sustain deep vaginal and perineal lacerations. Though lacerations cannot be prevented during fetal birth, the extent of the lacerations can be reduced. Fetal birth occurs as the fetal head is rapidly expelled from the vagina. The pressure produced during the sudden fetal birth results in deep vaginal and perineal lacerations. Therefore, the flat side of the hand is placed on the exposed fetal head and gentle pressure is applied toward the vagina. This prevents the fetal head for popping out, and prevents lacerations. The nurse should place clean material under the client's buttocks to reduce the soiling of linen due to vaginal bleeding during birth. The client's vaginal area should not be touched during birth in order to avoid infection and provide privacy to the client. Rapid birth of the fetal head causes a rapid change of pressure within the molded fetal skull, which could result in dural or subdural tears. Therefore, this intervention does not aid in reducing lacerations.

Middle Eastern

Arab orMiddle Eastern_ women may be vocal in response to labor pain. They may prefer medication for pain relief.

The nurse providing care for the laboring woman understands that accelerations with fetal movement: Are reassuring Are caused by umbilical cord compression Warrant close observation Are caused by uteroplacental insufficiency

Are reassuring Rationale Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.

Amniotomy

Artificial rupture of membranes (AROM, ARM)."

Stage 3 Interventions

Assess maternal vital signs. Assess uterine status. Provide parents with an explanation regarding delivery of the placenta. Examine placenta for cotyledons and membranes to verify that it is intact.

What instructions does the nurse give to reduce the risk of urinary retention in a client during labor? Ask the client to void in a lateral position. Ask the client to increase her fluid intake. Ask the client to empty her bladder every 4 hours. Assist the client with techniques to help stimulate voiding.

Assist the client with techniques to help stimulate voiding. Rationale The client may not feel the urge to void during labor. The nurse should palpate the bladder for distention and ask the client to void spontaneously by using voiding techniques like running water. The nurse should ask the client to void in an upright position rather than in a lateral position. The client should not increase her fluid intake, because it may not help in voiding. The nurse should ask the client to empty her bladder every two hours.

Resting Tone

Average resting tone during labor is 10 mm Hg (should be no palpable resistance)

A variety of medications may be administered to women during labor. Which medication is used to reduce anxiety, potentiate the effects of analgesics, and relieve nausea? A) Naloxone (Narcane) B) Metoclopramide (Reglan) C) Promethazine (Phenergan) D) Fentanyl Citrate (Sublimaze)

B) Metoclopramide (Reglan)

assessment during 4th stage of labor

BP Q15 min for 2 hr pulse - rate and regularity Q15 min for the first 2 hrs Temp - at the beginning of the recovery period, Q4R for the first 8 hr after birth and then at least Q8R

Fetal Tachycardia

Baseline FHR greater than 160 bpm for 10 minutes or longer - can be considered an early sign of fetal hypoxemia especially when associated with late decelerations and minimal or absent variability

The nurse assesses the fetal heart rate (FHR) of a pregnant client and finds minimal FHR variability. The nurse reassesses the client 30 minutes later and finds moderate variability. What should the nurse infer? No acceleration. Late deceleration. Baseline heart rate is 150 beats/minute. Baseline heart rate is 180 beats/minute.

Baseline heart rate is 150 beats/minute. Rationale If the nurse notes minimal FHR variability, the nurse should reassess the heart rate to determine a pattern. If in 30 minutes the nurse notices moderate variability, the fetus may be in a sleep state. The nurse would further confirm after half an hour and report it as moderate variability when the heart rate baseline is confirmed as normal, i.e., 110 to 160 beats/minute. Heart rate variability is a characteristic of the baseline FHR and does not include accelerations or decelerations of the FHR. A fetal baseline heart rate of 180 beats/minute is severe variability.

Which maternal behaviors indicate a need to abbreviate the initial assessment when a patient comes into the intrapartum unit? Select all that apply. Bearing down Low-pitched, guttural sounds Decrease in contractions with activity Sociable, excited, and somewhat anxious A statement such as, "The baby's coming!"

Bearing down Bearing down suggests imminent birth. Low-pitched, guttural sounds Grunting sounds suggests imminent birth. A statement such as, "The baby's coming!" Saying urgently something like "The baby's coming" suggests imminent birth.

Late Deceleration

Begins after the contraction has started -onset (nadir) occurs after the peak of the contraction -Decelaration usually does not return to baseline until after the contraction is over -indicate disrupted o2 transfer to the fetus

Which characterizes a patient's discomfort during the active phase of labor? Felt in the abdomen and groin May be more annoying than truly painful Little discomfort; sometimes slight cramp is felt as placenta is passed Begins with a low backache with sensations similar to menstrual cramps and intensifies as labor progresses

Begins with a low backache with sensations similar to menstrual cramps and intensifies as labor progresses During the active phase of labor discomfort typically begins with a low backache and intensifies as the contractions continue to progress.

Which type of vaginal discharge is more common during the transition phase of the first stage of labor? Bloody mucus Pale pink mucus Brownish discharge Pink-to-bloody mucus

Bloody mucus Rationale During the transition phase, the cervix is dilated to 8 to 10 cm, which results in the appearance of bloody mucus in the vaginal discharge. Pale pink mucus is seen in the latent phase, in which the cervix dilates to not more than 3 cm. Brownish discharge may also be observed during the latent phase of the first stage of labor. Pink-to-bloody mucus is observed in the active phase of cervical dilation.

Modified-Paced Breathing

Breathing is shallow and fast. Used when slow-paced breathing is no longer effective.

What are the different parts of the true pelvis? Select all that apply. Brim Outlet Android Midpelvis Anthropoid

Brim Outlet Midpelvis Rationale The true pelvis is involved in the birth process and is divided into three planes: the inlet, or brim; the midpelvis, or cavity; and the outlet. The brim or the pelvic inlet is the upper border of the true pelvis. It is made up of the upper margins of the pubic bone anteriorly and the iliopectineal lines along the innominate bones laterally. Posteriorly, it has the anterior upper margin of the sacrum and the sacral promontory. The pelvic outlet is the lower border of the true pelvis. It is ovoid and diamond shaped. It has the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly. The midpelvis, or the pelvic cavity, is a curved passage. It has a short anterior wall and a longer concave posterior wall. It has the posterior aspect of the symphysis pubis, the ischium, a portion of the ilium, the sacrum, and the coccyx. Android and anthropoid are the different basic types of the pelvis.

Following administration of fentanyl (Sublimaze) IV for pain associated with uterine contractions, a woman's labor progresses more rapidly than expected. The physician orders that a stat dose of naloxone (Narcan) 1 mg IV be administered to the women to reverse respiratory depression in the newborn after its birth. In fulfilling this order, the nurse knows to: A) Question the route, because this medication should be administered orally. B) Recognize that the dose is too low. C) Assess the woman's level of pain, because it will return abruptly. D) Observe the maternal pulse for bradycardia.

C) Assess the woman's level of pain, because it will return abruptly.

In her birth plan, a women requests that she be allowed to use the new whirlpool bath during labor. When implementing this women's request, the nurse should: A) Assist the women to maintain a reclining position when in the tub. B) Tell the women she will need to leave the tub as soon as her membrane ruptures. C) Begin hydrotherapy when the women is in active labor (approximately 5 cm). D) Limit her to no longer than 1 hour in the tub.

C) Begin hydrotherapy when the women is in active labor (approximately 5 cm).

Montevideo Units (MVUs)

CALCULATED BY SUBTRACTING THE BASELINE UTERINE PRESSURE FROM THE PEAK CONTRACTION PRESSURE FOR EACH CONTRACTION THAT OCCURS IN A 10 MINUTE PRESSURE THAN ADDING TOGETHER THE PRESSURES GENERATED BY EACH CONTRACTION Range from 100-250 in first stage; may rise to 300-400in second stage. Contraction intensities of 40 mm Hg or more and MVUs of 80-120 are generally sufficient to initiate spontaneous labor

Common prenatal lab tests

CBC hgb & hct type and screen RPR Rubella titer TB skin test Hepatitis B screen HIV screen UA STD screen & pap smear MSAFP Multiple marker screen Glucose challenge test Vaginal/Rectal cultures

Prolonged Decelerations

Can be gradual or abrupt; fetal heart rate decreased by at least 15 bpm below the baseline and lasts more than 2 minutes but less than 10 minutes

Urine specimen

Can be used to determine hydration status (specific gravity, color, amount), nutritional status (ketones), infection status (leukocytes), or the status of possible complications such as preeclampsia (proteinuria)

Variable decelerations

Caused by conditions that restrict flow thru the umbilical cord. Do not have the uniform appearance of early and late decelerations. -Shape, duration, and degree of decline below baseline FHR are variable. These fall and rise abruptly with the onset and relief of cord compression. Nonperiodic-Occur at times unrelated to contractions. Interventions- <70 bpm for 1 min; change position of mother, admin Oxygen, D/C Oxytocin (Pitocin), assess mother's vital signs. Notify MD, Assist with amnioinfusion- intrauterine instillation of warmed saline to decrease compression on umbilical cord.

Increased fetal heart rate due to

Central Nervous System

The sonographic reports of a pregnant client reveal extreme asynclitism of the fetal head. What does the nurse conclude from this report? The fetal head is parallel to the anteroposterior plane of the pelvis. The client will have a normal vaginal delivery. The position of the fetal head will facilitate descent. Cephalopelvic disproportion will be seen during labor.

Cephalopelvic disproportion will be seen during labor. Rationale Extreme asynclitism of the fetal head makes the fetus unable to descend during the birth process and causes cephalopelvic disproportion. The fetal head is parallel to the anteroposterior plane of the pelvis in a synclitic position. The client will most probably have a cesearean delivery because extreme asynclitism indicates that the fetal head is deflected in a way that may interfere with vaginal delivery. Asynclitism, not extreme asynclitism, facilitates fetal descent, because the head is being positioned to accommodate the pelvic cavity.q

The nurse is assessing a pregnant client and uses spiral electrode monitoring to record the fetal heart rate. Under what circumstances can the nurse consider implementing this method? Cervix has partially dilated. Uterine contractions have increased. The client's placenta cannot be ruptured. Umbilical cord is compressed.

Cervix has partially dilated. Rationale Spiral electrode monitoring is used to determine the fetal heart rate during the intrapartum period. Because the spiral electrode is introduced into the cervix, the nurse needs to make sure that the client's cervix is partially dilated. This allows the nurse to properly place the equipment to hear the heart sounds of the fetus. Ruptured placental membranes are also one of the considerations for using spiral electrode monitoring. A compressed umbilical cord and increased uterine contractions (UCs) are not factors that are considered for using a spiral electrode.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by what? Change in position Oxytocin administration Regional anesthesia Intravenous analgesic

Change in position Rationale Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output.

A physical care measure for a laboring woman that has been identified as unlikely to be beneficial and may even be harmful is: A. Allowing the laboring woman to drink fluids and eat light solids as tolerated B. Administering a Fleet enema at admission C. Ambulating periodically throughout labor as tolerated D. Using a whirlpool bath once active labor is established"

Choice B is correct; research has indicated that enemas are not needed during labor; according to research findings, choices A, C, and D have all been found to be beneficial and safe during pregnancy." B. Administering a Fleet enema at admission

When admitting a primigravida to the labor unit, the nurse observes for signs that indicate that the woman is in true labor and should be admitted. The nurse recognizes which of the following signs as indicative of true labor? (Circle all that apply.) A. Woman reports that her contractions seem stronger since she walked from the car to her room on the labor unit. B. Cervix feels soft and is 50% effaced. C. Woman perceives pain to be in her back or abdomen above the level of the navel. D. Fetus is engaged in the pelvis at zero station. E. Cervix is in the posterior position. F. Woman continues to feel her contractions intensify following a back rub and with use of effleurage."

Choices A, B, D, and E are correct; pain of true labor is usually felt in the lower back radiating to the lower portion of the abdomen." A. Woman reports that her contractions seem stronger since she walked from the car to her room on the labor unit. B. Cervix feels soft and is 50% effaced. D. Fetus is engaged in the pelvis at zero station. E. Cervix is in the posterior position.

Relaxation Time Between Contractions

Commonly 60 seconds or more in second stage

When performing Leopold's First Maneuver, the nurse palpates the uterine fundus and suspects a breech fetal presentation. Which action should the nurse take if breech presentation is supported after the second and third Leopold's maneuvers? Wash hands with warm water. Proceed to the fourth maneuver. Explain the procedure to the woman. Complete Leopold's Maneuver and alert the healthcare provider.

Complete Leopold's Maneuver and alert the healthcare provider. This maneuver is only completed in cephalic presentations to determine if the fetal head is flexed.

What interventions does the nurse perform to provide emotional support to a client in labor? Compliment client efforts during labor. Avoid offering food during labor. Use a calm, confident approach. Discourage activities that distract. Involve the client in care decisions.

Compliment client efforts during labor. Use a calm, confident approach. Involve the client in care decisions.

Which characteristics of contractions are indicative of true labor in a primigravida? Select all that apply. Lightening Contractions remain consistent in intensity Contractions begin in abdomen, but spread Consistent contractions increasing in duration Progressive effacement and dilatation of the cervix

Consistent contractions increasing in duration Contractions occurring in a consistent pattern of increasing duration indicate true labor. Progressive effacement and dilatation of the cervix There is progressive effacement and dilatation of the cervix during true labor.

Duration of Contractions

Contraction duration remains fairly stable throughout first and second stages, ranging from 45-80 seconds

Mild

Contraction presents with a slightly tense fundus that is easy to indent with fingertips (feels like pressing tip of nose)

Moderate

Contraction presents with firm fundus that is difficult to indent with fingertips (feels like pressing finger to chin)

Stage 3 Assessment

Contractions occur until the placenta is expelled. Monitor client for signs of placental separation. Delivery of placenta occurs 5 to 30 minutes after birth of baby. Schultze's mechanism: Center portion of placenta separates first and its shiny fetal surface emerges from the vagina. Duncan's mechanism: Margin of placenta separates and the dull, red, rough maternal surface emerges from the vagina first.

Labor

Coordinated sequence of involuntary intermittent uterine contractions

The physician has ordered nalbuphine hydrochloride (Nubain) 10 mg IV every 3 to 4 hours as needed for pain associated with labor. In fulfilling this order, the nurse knows that: A) This medication is a potent opioid agonist analgesic. B) The dosage of the analgesic is too high for IV administration, necessitating a new order. C) This is the analgesic of choice if the laboring women is opioid dependent. D) This analgesic is unlikely to cause significant maternal or fetal/neonatal respiratory depression.

D) This analgesic is unlikely to cause significant maternal or fetal/neonatal respiratory depression.

Variable Deceleration

Decrease in FHR below the baseline (onset to nadir less than 30 seconds) -decrease is at least 15 bpm or more below the baseline, lasts at least 15 seconds, and returns to baseline in less than 2 minutes -have a U, V, or W shape -sometimes preceded and followed by brief accelerations of the FHR known as shoulders

Which characteristic is associated with false labor contractions? Painless Decrease in intensity with ambulation Regular pattern of frequency established Progressive in terms of intensity and duration

Decrease in intensity with ambulation Rationale Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. True labor contractions are painful. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.

When teaching a childbirth class for first-time parents, the nurse includes which benefits of breathing techniques used during labor? Decreased sensation of pain Increased energy with continued use Provides a different focus during contractions Can be combined with pharmacologic therapies Can be used with other nonpharmacologic techniques

Decreased sensation of pain The sensation of pain is decreased with breathing techniques. Provides a different focus during contractions Breathing techniques provide laboring women with a different focus during contractions, reducing the perception of pain. This is a benefit of using breathing techniques in labor Can be used with other nonpharmacologic techniques Breathing techniques can be used to supplement other relaxation techniques during labor, such as mental stimulation and cutaneous stimulation

Early decelerations

Decreases in FHR below baseline; rare at lowest point and remains greater than 100bpm Occur during contractions as fetal head is pressed against the mothers pelvis or soft tissues and return to baseline FHR by end of contraction -Tracing shows a uniform shape and mirror image of uterine contractions. Not associated with fetal compromise and require no interventions

Cesarean section

Delivery of the fetus usually through a transabdominal, low-segment incision of the uterus.

Childbirth Preparation Methods

Dick-Read Method- relaxing each muscle group throughout the body during labor Lamaze Method- muscle relaxation and breathing(psychoprophylaxis) Bradley Method- all natural, only breathing and relaxation (husband coached childbirth)

The nurse cares for a woman experiencing a difficult labor. Due the psychological effects of the long and painful labor and delivery, the nurse knows that the patient may experience which consequence? Chronic fatigue Loss of identity Postpartum psychosis Difficulty bonding with infant

Difficulty bonding with infant As a result of a difficult labor and delivery, a new mother may find it difficult to interact with her infant because she may feel physically and emotionally depleted.

While performing a vaginal examination of the client in active labor, the nurse notes early decelerations in the fetal heart during uterine contractions. What should the nurse do in this situation? Stop applying fundal pressure. Discontinue the oxytocin (Pitocin) drip. Change the maternal position. Document it as a normal finding.

Document it as a normal finding. Rationale Early decelerations in the FHR are common during UCs. These decelerations may also happen due to increased fundal pressure and during placement of the internal mode of fetal monitoring. Applying fundal pressure during vaginal examination helps in accurate assessment; therefore, fundal pressure needs to be applied. Oxytocin (Pitocin) administration induces UCs and indirectly causes the FHR to decelerate, but the medication should not be discontinued. The nurse would have the client change positions if the umbilical cord was compressed.

False Labor

Does not produce dilation, effacement or descent Contractions are irregular w/o progression Activity such as walking, drinking fluids relieves false labor

Which part of the labor contraction cycle is the nurse describing when stating, "Contractions are lasting 40 to 50 seconds?" Duration Increment Decrement Frequency

Duration Duration is the length of each contraction from beginning to end; it is usually expressed in seconds.

During the latent phase of the first stage of labor the cervix dilates up to _______________________________ cm in approximately _______________________________ to _______________________________ hours. Cervical dilation progresses from _______________________________ to _______________________________ cm in about ________ _______________________ to _______________________________ hours during the active phase of the first stage of labor. The duration of the transition phase is approximately _______________________________ to ___________ ____________________ minutes and the cervix dilates from _______________________________ to _______________ ________________ cm."

During the latent phase of the first stage of labor the cervix dilates up to 3 cm in approximately 6 to 8 hours. Cervical dilation progresses from 4 to 7 cm in about 3 to 6 hours during the active phase of the first stage of labor. The duration of the transition phase is approximately 20 to 40 minutes and the cervix dilates from 8 to 10 cm.

The nurse is monitoring the fetal heart rate (FHR) of a client. When would the nurse observe early decelerations? During uterine contractions When external sound is applied When the abdomen is palpated During regular fetal movement

During uterine contractions Rationale Compression of the fetal head during uterine contraction can cause early decelerations. Fetal heart rate accelerations occur in response to applying external sounds. Palpation of the abdomen also causes FHR accelerations, but not decelerations. Spontaneous and regular fetal movement indicates fetal well-being and results in FHR accelerations.

Cleansing Breath

Each contraction begins and ends with a deep inspiration and expiration.

Stage 1

Effacement and dilation of cervix 3 stages: Latent, Active, Transition Mother is talkative and eager in Latent phase, becoming tired, restless, and anxious as labor intensifies and contractions become stronger. Interventions: Monitor VS, FHR, before and after contraction, assess status of cervical dilation and position by Leopold's maneuvers. Pelvix exam and fern test. Ruptured membranes- assess FHR, color of amniotic fluid

. _______________________________ Federal regulation enacted to ensure that pregnant women obtain the care they require during emergencies and when in labor regardless of their insurance status or ability to pay."

Emergency Medical Treatment and Active Labor Act

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. What measures are included? Encouraging the woman to try various upright positions, including squatting and standing. Telling the woman to start pushing as soon as her cervix is fully dilated. Continuing an epidural anesthetic so that pain is reduced and the woman can relax. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

Encouraging the woman to try various upright positions, including squatting and standing. Rationale Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

Dilation

Enlargement and widening of the cervical opening (os) and the cervical canal that occurs during labor. Progress is expressed in centimeters from less than 1 cm to 10 cm when complete

Recommended Intermittent Auscultation (IA) Frequency

Ever 15 to 30 minutes in the active phase of the first stage of labor and every 5 to 15 minutes in the active phase of the second stage of labor

A pregnant client is anxious about the pain that she may experience during labor. What does the nurse include in the prenatal teaching to relieve anxiety in this client? Avoids discussing any negative feelings Explores different relaxation techniques Discusses the different stages of labor Explains that pain is part of the birthing process

Explores different relaxation techniques Rationale The nurse should encourage the woman to explore different relaxation techniques that can be used to relieve pain during labor. The nurse should also encourage the client to express any negative feelings to relieve her anxiety. Providing factual information regarding the different stages of labor makes the client aware of the entire process but does not help relieve anxiety. Telling the client that pain is a part of the birthing process does not help relieve anxiety. Instead, the nurse should discuss the different pharmacologic and nonpharmacologic pain relief measures.

Expulsion

Expulsion is the birth of the entire body.

Stage 2

Expulsion of fetus Pushing stage Mother has intense concentration on pushing with contractions; may fall asleep b/w contractions Interventions: cervical dilation complete, descent of fetal head, bloody show, mother feels urge to bear down. Perineal bulging or visual of fetal head Assess q5min, Monitor VS, FHR, uterine contractions

Shultz mechanism

Expulsion of placenta with fetal side emerging first.

How does cephalic presentation of the fetus facilitate labor? Select all that apply. Facilitates dilatation Facilitates the delivery of the fetal buttock first Allows the fetal head to adapt to the maternal pelvis Hastens labor, due to the need for caesarean section Enables fetal parts to be born from smallest to largest

Facilitates dilatation The fetal head is smooth, round, and hard, making it an effective part to dilate the cervix, which is also round. Allows the fetal head to adapt to the maternal pelvis During labor the fetal head can gradually change shape to adapt to the size and shape of the maternal pelvis.

iran

Father not present; female support and female caregivers preferred

Match the invasive fetal surveillance method to the correct advantage.

Fetal scalp electrode Accuracy of fetal heart rate Solid intrauterine pressure catheter (IUPC) Accuracy of uterine contractions; also has an additional lumen for amnioinfusion Fluid-filled catheter intrauterine pressure catheter (IUPC) Accuracy of uterine contractions, including intensity and resting tone

Match the stage of labor with the expected event.

First stage Cervical effacement and dilatation from onset of true labor to complete dilatation Second stage Complete cervical dilatation and effacement to birth of the baby Third stage Birth of the baby to expulsion of the placenta Fourth stage Expulsion of the placenta to physical recovery of mother and infant (1 to 4 hours postpartum)

A client sustained perineal lacerations involving the anterior rectal wall during childbirth. What is the severity of the client's perineal laceration? First degree Second degree Third degree Fourth degree

Fourth degree Rationale Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. Lacerations that also involve the anterior rectal wall are classified as fourth degree. Lacerations that extend through the skin and the structures superficial to muscles are classified as first degree. Lacerations that extend through the muscles of the perineal body are classified as second degree. Lacerations that continue through the anal sphincter muscle are classified as third degree.

Which condition often occurs in a nulliparous client in contrast with a multiparous client during labor? An increase in the speed of fetal descent Less fatigue and pain due to a short labor Greater sensory labor pain during easy labor Greater sensory pain in the second stage of labor

Greater sensory labor pain during easy labor Rationale A nulliparous client may experience greater sensory labor pain during easy labor as compared to a multiparous client. This is because her reproductive tract structures are less flexible. The firmer tissues in nulliparous clients as compared to the flexible tissues in multiparous clients result in a gradual fetal descent. A nulliparous client has a longer labor and therefore experiences greater fatigue. A rapid fetal descent in the second stage of labor occurs in multiparous clients and causes greater sensory pain.

Semirecumbent Position

HOB elevated at least 30 degrees. The greater the angle of elevation, the more gravity or pressure is exerted that promotes fetal descent, the progress of contractions, and the widening of pelvic dimensions.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware of what? Either hot or cold applications may provide relief, but they should never be used together in the same treatment Acupuncture can be performed by a skilled nurse with just a little training Hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited Therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations

Hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited Rationale The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: Notify the woman's physician. Tell the woman to slow the pace of her breathing. Administer oxygen via a mask or nasal cannula. Help her breathe into a paper bag

Help her breathe into a paper bag. This client is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, and circumoral numbness. Notification of the physician is not necessary. The best approach is to have the client breathe into a paper bag held tightly around the nose and mouth to eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Slowing the pace of her breathing will not correct the problem, nor will administration of oxygen. Once the pattern of breathing is corrected, her partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues.

Frequency "

How often uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next contraction."

Frequency

How often uterine contractions occur; the time that passes from the beginning of one contraction to the beginning of the next

The nurse measures the uterine contraction strength during labor at 500 MVUs. Which type of uterine contraction strength does this indicate? Normal Moderate Hypotonic Hypertonic

Hypertonic Above 400 MVUs the uterine contraction strength is considered hypertonic, which is abnormal.

Which physiologic conditions does the nurse assess in a pregnant client who is experiencing pain during labor? Select all that apply. Hyperventilation Nausea and vomiting Increased blood pressure Increased placental perfusion Increased catecholamine levels

Hyperventilation Nausea and vomiting Increased blood pressure Increased catecholamine levels Rationale The client experiences physiologic effects due to pain during labor. The patient may experience hyperventilation when the pain intensifies and more rapid shallow breathing occurs. Nausea and vomiting may be seen if the client experiences gastric acidity in the active and transition phases of the first stage of labor. The client 's blood pressure may increase due to the stress experienced in labor. An increase in catecholamine levels may be seen as the sympathetic nervous system activity is stimulated in response to pain. Pain decreases placental perfusion and diminishes uterine activity.

What does the nurse need to do if she sees Category III FHR tracings?

Immediately evaluate patient and baby and intervene promptly -notify provider

Western

In __ societies, the father is often viewed as the ideal birth companion

vertex

In a __ presentation, you can usually hear the FHR below the mother's umbilicus in either the right or left lower quadrant of the abdomen

breech

In a __ presentation, you usually hear the FHR above the mothers umbilicus.

Which factor is associated with the reduced pain and feelings of euphoria in a pregnant client during labor? Use of hydrotherapy Use of distraction techniques Increase in catecholamine levels Increase in beta-endorphin levels

Increase in beta-endorphin levels Rationale Beta-endorphins are endogenous opioids secreted by the pituitary gland and are associated with feelings of euphoria. An increase in beta-endorphin levels increases the pain threshold so that the client is able to endure acute pain during labor. Hydrotherapy facilitates birth and can reduce labor pains, but is not associated with feelings of euphoria. Distraction techniques help reduce pain as the client focuses on other things apart from the pain. However, they are not associated with euphoria. An increase in catecholamine levels indicates that the client is experiencing more stress.

The nurse is caring for a client in the last trimester of pregnancy. What assessments will the client display related to the effects of fear and anxiety during labor? Increased blood flow Increase in the progression of labor Increased contractions Increase in muscle tension

Increase in muscle tension Rationale Fear and excessive anxiety lead to increased muscle tension. This causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus, fear and anxiety magnify the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions, leading to increased discomfort. This slows the progress of labor.

The nurse notes fetal tachycardia and suspects that the mother may be dehydrated. Which nursing action is appropriate to address this nonreassuring finding? Consult with the dietician Administer parenteral feeding Increase the rate of IV saline administration Provide the mother an electrolyte replacement PO

Increase the rate of IV saline administration Tachycardia can be the result of maternal hypovolemia, due to dehydration. Increasing the rate of nonadditive intravenous fluids can improve placental perfusion by increasing maternal blood volume.

Which is a physiological effect resulting from labor pain? Decreased metabolic rate Increased uterine blood flow Decreased maternal demand for oxygen Increased production of catecholamines

Increased production of catecholamines The production of "fight-or-flight" hormones increase as a result of labor pain and anxiety. These include the catecholamines epinephrine and norepinephrine.

Amnioinfusion

Infusion of room-temperature, isotonic fluid (usually lactated Ringer's solution, usual normal saline) -helps relieve intermittent umbilical cord compression that results in variable decelerations and transient fetalhypoxemia(occurs when membranes rupture and amniotic fluid is no longer there to prevent cord compression) POSSIBLE SIDE EFFECTS -overdistention of the uterine cavity -increased uterine tone (resting tone should not exceed 40 mm Hg)

Lumbar epidural block

Injection site is in epidural space. -Block administered after labor is established or before scheduled c-section. -Anesthetic relives pain from contractions and numbs vagina and perineum. -Block may cause hypotension, bladder distention and prolonged 2nd stage but observe for S/E: N/V, pruritus, respiratory dispression -Does not cause H/A- dura mater not penetrated. Assess maternal BP in side lying position or place rolled blanket beneath (R) hip to displace the uterus from vena cava.

Which represent potential causes of uterine hemorrhage after birth? Select all that apply. Secretion of oxytocin Injury to the birth canal Continued uterine contractions Cessation of uterine contractions

Injury to the birth canal Injury to the birth canal, such as cervical or vaginal tears, can lead to excessive bleeding. Cessation of uterine contractions Typically, contraction of the uterine muscle compresses the vessels, which reduces bleeding. When uterine contractions are absent, excessive bleeding is likely.

Four major factors (four Ps)

Interact during normal childbirth Interrelated and depend on each other for a safe delivery Include: Powers, Passageway, Passenger, Psyche

Which order would the nurse expect to administer to a patient at high risk for maternal hypotension prior to epidural anesthesia? Intravenous fluids Drugs to raise gastric pH Drugs to reduce oral secretions Drugs to speed gastric emptying

Intravenous fluids The nurse would anticipate intravenous fluids, which should be administered prior to epidural anesthesia.

The nurse is teaching a client, who is pregnant for the first time, about the signals that indicate the beginning of labor. Which sign will the nurse mention as a signal for the beginning of labor? Involuntary contractions Pain in the pelvic joints 100% effacement of the cervix Full dilation of the cervix

Involuntary contractions Rationale Involuntary uterine contractions, or the primary powers, signal the beginning of labor. Pain in the pelvic joints does not signal the beginning of labor. It is a result of widening of the joint of the symphysis pubis and the resulting instability. The primary powers are responsible for the effacement and dilation of the cervix and the descent of the fetus. Effacement is the shortening and thinning of the cervix during the first stage of the labor. However, 100% effacement would indicate that the patient is well established in the labor process. Dilation of the cervix is the enlargement or widening of the cervical opening and cervical canal. This dilation progresses after the labor has begun. Full cervical dilation marks the end of the first stage of labor.

Variability of FHR

Irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater -does not include accelerations or decelerations of the FHR -measured from the peak to the trough of a single cycle -4 categories of variability: absent, minimal [either abnormal or indeterminate], moderate, marked

The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? It is diamond-shaped in appearance. It measures about 1 cm by 2 cm. It closes after 6 to 8 weeks of birth. It lies near the occipital bone.

It is diamond-shaped in appearance. Rationale The anterior fontanel is diamond-shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm. It closes after 6 to 8 weeks of birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone.

When assessing a client for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? It is the part above the brim of the bony pelvis. It is movable in the latter part of the pregnancy. It has three planes, the inlet, midpelvis, and outlet. It is ovoid and bound by pubic arch anteriorly.

It is movable in the latter part of the pregnancy. Rationale The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is the ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly.

Which examples demonstrate how labor pain is different from other types of pain? Select all that apply. Labor pain is intermittent. Labor pain has a foreseeable end. Childbirth pain is part of a normal process. Woman can acquire skills to help manage labor pain. Childbirth pain is intensified by the emotional component of delivering an infant.

Labor pain is intermittent. A woman may experience little discomfort with contractions, and she may be relatively comfortable during the short rest periods between contractions. This makes labor different from other types of pain. Labor pain has a foreseeable end. A woman can expect her labor to end within hours, rather than days, weeks, or months, whereas other types of pain may not have a foreseeable end. Childbirth pain is part of a normal process. Childbirth pain is part of a normal process, whereas other types of pain usually indicate an injury or illness. Woman can acquire skills to help manage labor pain. Different from other types of pain, pain associated with the birth process can be addressed, in part, by realistic preparation and knowledge about the birth process.

The nurse is assessing a client in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? Latent phase Active phase Transition phase Descent phase

Latent phase Rationale The client is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase or active pushing phase occurs in the second stage of labor. In this phase, the client has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

1st stage of labor phases

Latent, Active and Transition with epidural transitional phase may not be identified

If a woman complains of back labor pain, what is the best suggestion by the nurse? Lie on her back for a while with her knees bent Do less walking around Take some deep, cleansing breaths Lean over a birth ball with her knees on the floor

Lean over a birth ball with her knees on the floor Rationale The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. Deep cleansing breaths will assist with any labor pain; however, it is very important that this woman's position is changed so that she is not on her back.

If a woman complains of back labor pain, the nurse might best suggest that she: Lie on her back for a while with her knees bent. Do less walking around. Take some deep, cleansing breaths. Lean over a birth ball with her knees on the floor.

Lean over a birth ball with her knees on the floor. The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. Deep cleansing breaths will assist with any labor pain; however, it is very important that this woman's position is changed so that she is not on her back.

Mechanisms of Labor

Lightening or dropping -Braxton Hicks increase -Vaginal mucosa is congestion; vaginal discharge increases -Brownish or blood-tinged cervical mucus is passed -Cervix ripens, becomes soft and partly effaces, dilate -Mother has sudden burst of energy "Nesting"- 24-48 hrs before onset of labor Wt loss of 1-3 lbs r/t fluid shifts d/t progesterone and estrogen levels -Spontaneous rupture of membranes

signs preceding labor

Lightening, return of urinary frequency, backache, stronger braxton Hicks contractions, weight loss of 0.5 to 1.5 kg ( water loss, electrolyte shift, changes in estrogen progesteron levels lead to surge of energy, increased vaginal discharge, bloody show, cervical ripening, possible rupture of membranes.

Which is one of the best positions in which to place the mother in case of complications during delivery? Prone position Maternal position Lithotomy position Side-lying position

Lithotomy position Rationale The lithotomy position makes dealing with some complications that arise more convenient for the nurse-midwife or physician. To place the woman in this position, bring her buttocks to the edge of the bed or table and place her legs in stirrups. Prone and side-lying positions are not best for complications during delivery. The maternal position for birth in a birthing room varies from a lithotomy position, with the woman's feet in stirrups or resting on footrests, or with her legs held and supported by the nurse or support person, to one in which her feet rest on footrests while she holds on to a squat bar, to a side-lying position with the woman's upper leg supported by the coach, nurse, or squat bar.

Stage 1 (1. Latent phase)

Longest stage A labor curve (Friedman) used to identify whether a woman's cervical dilation is progression at expected rate. S/S Cervical dilation 1-4cm* Uterine contractions occur every 15-30 mins; 15-30 sec in duration; mild intensity Interventions: comfort measures, change positions, keep family informed of progress, offer fluids, encourage voiding 1-2 hours

The nurse is assessing a pregnant client who is due in 2 weeks. Which signs and symptoms preceding labor may the nurse expect to see in the client? . Loss of weight Pain in the groin Persistent low backache Loss of energy Blood-tinged cervical mucus

Loss of weight Pain in the groin Persistent low backache Blood-tinged cervical mucus Rationale The pregnant client may have a weight loss of 0.5 to 1.5 kg in the days preceding labor, due to water loss from electrolyte shifts, caused by changes in estrogen and progesterone levels. Pain in the groin and persistent low backache may occur due to the relaxation of the pelvic joints. The extreme congestion of the vaginal mucous membranes may cause blood-tinged cervical mucus. A surge of energy is a common phenomenon in a pregnant client preceding labor.

pelvic outlet

Lower border of the true pelvis. bounded by the pubic arch anteriorly. the ischial tuberosities laterally and the tip of the coccyx posteriorly

When caring for a client in the first phase of labor, the nurse observes that the client is experiencing visceral pain. In which area does visceral pain occur? Abdominal wall and thighs Gluteal area and iliac crests Lumbosacral area of the back Lower portion of the abdomen

Lower portion of the abdomen Rationale Visceral pain in the first stage of labor occurs in the lower portion of the abdomen. Visceral pain is a result of distention of the lower uterine segment and stretching of cervical tissue as it effaces and dilates. Pressure and traction on uterine tubes, ovaries, ligaments, nerves, and uterine ischemia also cause visceral pain. Pain that originates in the uterus radiates to the gluteal area, iliac crests, abdominal wall, thighs, lumbosacral area of the back, and lower back. This pain is called referred pain.

The nurse is caring for a client in the first stage of labor. Which nerve segments transmit pain impulses during this stage? Select all that apply. Lumbar spinal nerve segment L1 Pudendal nerve through S2 to S4 T10 to T12 spinal nerve segments Parasympathetic nervous system Upper lumbar sympathetic nerves

Lumbar spinal nerve segment L1 T10 to T12 spinal nerve segments Upper lumbar sympathetic nerves Rationale Pain impulses during the first stage of labor are transmitted via the T10 to T12 and L1 spinal nerve segments, and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix. Pain impulses during the second stage of labor are transmitted through the pudendal nerve through S2 to S4 spinal nerve segments and the parasympathetic system.

CBC

Many hospitals require a __ be done before epidural anesthesia is initiated

On assessment, the nurse notices that the fetal heart rate is 100 beats/minute. What could be a possible cause for this condition? Maternal hypoglycemia. Chorioamnionitis. Low fetal oxygen supply. Decreased fetal hemoglobin levels.

Maternal hypoglycemia. Rationale A FHR of less than 110 beats/minute is referred to as bradycardia. Maternal hypoglycemia is a common cause of bradycardia in the fetus. Chorioamnionitis is an infection that also causes tachycardia in the fetus. Hypoxemia and anemia (decreased hemoglobin) of the fetus cause tachycardia, in which the heart rate is more than 160 beats/minute.

The nurse observes late decelerations of the fetal heart rate (FHR) in the second phase of labor of a pregnant patient. The nurse assesses the pregnant patient and elevates the lower extremities of the patient. Which assessment finding would be the reason for this nursing intervention? Placental abruption Maternal hypotension Maternal hemorrhage Uterine contractions

Maternal hypotension Rationale Late decelerations in the FHR may be caused by maternal hypotension. Elevating the lower extremities helps to control maternal hypotension and increase the blood flow to the uterus. Elevating the legs wound not control hemorrhage, placental abruption, or UCs in a pregnant patient.

Which assessments would the nurse perform to identify the cause of a fetal heart rate over 160 bpm? Select all that apply. Fetal position Maternal temperature Maternal hydration status Umbilical cord compression Maternal hemoglobin levels

Maternal temperature An elevated maternal temperature can cause fetal tachycardia (heart rate >160 bpm for ≥10 min) due either to a transfer of the elevated temperature to the fetus or to a transfer of an infection from mother to fetus. Maternal hydration status Maternal dehydration can cause fetal tachycardia (heart rate >160 bpm for ≥10 min) due to the hypovolemic status of the mother. Umbilical cord compression Fetal umbilical cord compression would result in a heart rate below 110 bpm. Maternal hemoglobin levels Severe maternal anemia, as determined by red blood cell or hemoglobin levels, is a potential cause for fetal tachycardia (heart rate >160 bpm for ≥10 min).

mexico

May be stoic about discomfort until second stage, and then may request pain relief; father and female relatives may be present

laos

May use squatting position for birth; father may or may not be present; female attendance preferred

fontanels

Membranous-filled spaces that are located where the sutures in the fetal skull intersect

Which examples are characteristics of Braxton Hicks contractions? Select all that apply. Increase with walking Menstrual-like cramping Consistently increase in frequency Are regular and last 40-60 seconds Occur every 5 minutes to 25 minutes

Menstrual-like cramping Braxton Hicks contractions typically increase with walking. Occur every 5 minutes to 25 minutes Braxton Hicks contractions are typically irregular and infrequent.

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? Meperidine (Demerol) Promethazine (Phenergan) Butorphanol tartrate (Stadol) Nalbuphine (Nubain)

Meperidine (Demerol) Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol and Nubain are opioid agonist-antagonist analgesics.

After monitoring the fetal heart activity the nurse documents the fetal heart rate (FHR) to be in category II, according to the three-tier FHR classification system. What findings would the nurse have observed? Minimal variability. Moderate variability. Less than 110 beats/minute. Accelerations were present.

Minimal variability. Rationale Minimum variability in the FHR indicates that there is insufficient oxygen supply to the fetus. This is categorized as a category II in a three-tiered FHR classification system. Moderate variability in FHR indicates the normal cardiac activity of the fetus, which is categorized under category I. Bradycardia (FHR less than 110 beats/minute) is categorized under category III. The FHR acceleration is completely absent according to category II and is present in category I.

cultural care

More than 30% of the population belongs to a cultural group other than non-Hispanic white. By 2050, more than half the population will will be members of cultural groups other than non-Hispanic white. Culturally sensitive care****

A patient has received fentanyl, and her respiratory status is rapidly declining. Which medication would the nurse anticipate administering to counteract the effects of this drug? Naloxone Nalbuphine Butorphanol Promethazine

Naloxone Naloxone counteracts opioid-induced respiratory depression.

india

Natural childbirth methods are preferred; father not usually present; female relatives usually present

japan

Natural childbirth methods practiced; may labor silently; may eat during labor; father may be present.

A nurse is caring for a patient in the first stage of labor who received intrathecal opioid analgesics for pain relief from uterine contractions. The nurse observes for which common side effects of these drugs? Select all that apply. Nausea Sedation Pruritus Vomiting Respiratory depression

Nausea Nausea is a common side effect of intrathecal opioid analgesics. These drugs may be used throughout the first stage of labor, and require only a very small dose injected into the subarachnoid space. These drugs allow the mother to feel her contractions, but not the pain. Pruritus Pruritus is a common side effect of intrathecal opioid analgesics. These drugs may be used throughout the first stage of labor and require only a very small dose injected into the subarachnoid space. These drugs allow the mother to feel her contractions, but not the pain. Vomiting Vomiting is a common side effect of intrathecal opioid analgesics. These drugs may be used throughout the first stage of labor and require only a very small dose injected into the subarachnoid space. These drugs allow the mother to feel her contractions, but not the pain.

A woman is administered fentanyl during labor and is still experiencing significant pain. Which order from the provider would the nurse anticipate for administration? Naloxone Butorphanol Promethazine Nitrous oxide

Nitrous oxide The nurse anticipates an order for nitrous oxide, which can be administered to a woman who is still experiencing pain after the administration of fentanyl.

In the current practice of childbirth preparation, emphasis is placed on what? The Dick-Read (natural) childbirth method The Lamaze (psychoprophylactic) method The Bradley (husband-coached) method No specific method, but a variety of techniques

No specific method, but a variety of techniques Rationale Encouraging expectant parents to attend class is most important, because preparation increases a woman's confidence and thus her ability to cope with labor and birth. Gaining in popularity are Birthing from Within and Hypnobirthing. Historically the Dick-Read is a popular childbirth method still in use. The goal is to encourage new parents to attend any one of the acceptable childbirth education programs. The Lamaze method is less focused on a "method" approach and more concerned with psychologic preparation for labor. Attendance at any available class should be encouraged. Bradley as well as other methods encourage women to choose the techniques that work best for them. Women are assisted to develop their own birth philosophy and then choose from a variety of skills to help cope with the labor process.

When the nurse is palpating "firm" contractions, how will the uterus feel? Indented easily with the palm of the hand Not readily indented, similar to the forehead Indented with some difficulty, similar to the chin Easily indented with the fingertips, similar to the tip of the nose

Not readily indented, similar to the forehead Firm contractions feel like the forehead. The abdomen from the outside is unable to indent.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? Call for help. Insert a Foley catheter. Start oxytocin (Pitocin). Notify the primary health care provider immediately.

Notify the primary health care provider immediately. Rationale To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. In addition, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately. Although it is always a good idea to have extra help during any unanticipated obstetric event, this is not the most important nursing measure at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus.

Legal Implications

Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of these interventions

During a sterile vaginal exam, the nurse finds that the fetal position is ROA. What is the presenting part of the fetus? Occiput Sacrum Scapula Mentum

Occiput Rationale The presenting part of the fetus is the part that appears first during the labor. The fetal position refers to the presenting part in relation to the mother's pelvis. The position is denoted by a three-part abbreviation. In this case, the letters ROA stand for right, occiput, and anterior. It means that the occiput is the presenting part and is located in the right anterior quandrant of the maternal pelvis. Sacrum will be denoted by the letter S. Scapula (shoulder) is denoted by Sc. Mentum (chin) is denoted by the letter M.

cervical injuries

Occur when the cervix retracts over the advancing fetal head. These lacerations occur at the lateral angles of the external os; most are shallow, and bleeding is minimal. Larger lacerations extend to the vaginal vault or beyond the vault into the lower uterine segment; serious bleeding may occur.

Ferguson reflex

Occurs when pressure of presenting part against pelvic floor stretch receptors results in a woman's perception of an urge to bear down

Crowning

Occurs when widest part of the head (biparietal diameter) distends the vulva just before birth."

Under which circumstance would a nurse perform a vaginal examination on a client in labor? On admission to the hospital at the start of labor When accelerations of the fetal heart rate (FHR) are noted On maternal perception of perineal pressure or the urge to bear down When membranes rupture During the duration stage of labor

On admission to the hospital at the start of labor On maternal perception of perineal pressure or the urge to bear down When membranes rupture Rationale Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM) a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. There isn't a duration stage of labor.

Purpose of Electronic FHR Monitoring

Ongoing assessment of fetal oxygenation

opioids

Opioids decrease maternal heart and respiratory rate and blood pressure, which affects fetal oxygenation. Therefore maternal vital signs and FHR and pattern must be assessed and documented prior to and after administration of opioids for pain relief (mom should be lying on her side when administering the medication)

The nurse is administering an amnioinfusion to a client with oligohydramnios. What risk should the nurse primarily monitor for during administration? Overdistension of the uterus High risk of placental abruption Fetal heart rate (FHR) accelerations Increased uterine contractions (UCs)

Overdistension of the uterus Rationale Oligohydramnios is the condition in which the client has low levels of amniotic fluid. In this condition the nurse should administer an amnioinfusion. During this process the nurse should assess the abdominal size to make sure the client is not receiving too much fluid. This may cause overdistention of the uterus. This procedure does not affect the uterine activity (UA), placental hemorrhage, or the FHR. Placental abruption would cause conditions such as oligohydraminos. Decelerations in the FHR, not accelerations, are observed in oligohydraminos.

Slowed fetal heart rate due to

Parasympathetic Nervous System

Presentation

Part of the fetus that enters the pelvic inlet first. 3 main types are cephalic (head first), breech (buttocks first), and shoulder

Graphic chart on which cervical dilation and station are plotted to assist in early identification of deviations from expected labor patterns."

Partogram"

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: Select all that apply. Passenger. Placenta. Passageway. Psychologic response. Powers. Position.

Passenger. Passageway. Psychologic response. Powers. Position. Rationale At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.

A nurse is caring for a patient who needs general anesthesia. Which statement most describes this patient? Patient with a vaginal infection Patient with severe pain from uterine contractions Patient needing anesthesia for a vaginal episiotomy Patient refusing regional and local anesthetic methods and needs a cesarean delivery

Patient refusing regional and local anesthetic methods and needs a cesarean delivery A patient who refuses regional and local anesthetic methods and needs a cesarean delivery does require general anesthesia.

What finding in a client indicates a potential risk for complications during the labor process? Maternal temperature of 99.7 o F Persistent dark red vaginal bleeding Intrauterine pressure of 50 mm Hg Contractions lasting for 70 seconds

Persistent dark red vaginal bleeding Rationale Dark red blood is indicative of an old uterine bleed which was left untreated. It may indicate fetal hypoxia. Therefore, a persistent flow of dark red vaginal bleeding is a sign of a potential complication during the process of labor. A maternal body temperature of 99.7 o F is normal and does not indicate any complication. Intrauterine pressure greater than 80 mm Hg is a sign of potential complications. Contractions lasting for more than 90 seconds may increase risk during labor.

What are the common signs that are observed in the days preceding labor? Persistent low backache Sudden increase in lethargy Blood-tinged cervical mucus Increase in weight up to 1.5 kg Profuse vaginal mucus

Persistent low backache Blood-tinged cervical mucus Profuse vaginal mucus Rationale Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes. In the days preceding labor women generally have a sudden surge of energy. They also experience a loss of 0.5 to 1.5 kg in weight. This is caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels.

Stage 4

Physical recovery 1-4 hours after expulsion of placenta Mother is tired, but is eager to become acquainted with her newborn. Monitor lochia discharge Moderate amount and red in color. Assessment: BP & pulse returns to prelabor level, Fundus remains contracted, in midline 1-2 fingerbreadths below umbilicus Interventions- Assess every q15min, ice packs to perineum, massage uterus, breast feeding support

During a prenatal evaluation, the nurse notes that the client has a flat pelvis. What term does the nurse use to refer to this type of pelvis? Gynecoid Android Anthropoid Platypelloid

Platypelloid Rationale About 3% of women may have flat pelvis, which is referred to as platypelloid pelvis. It is flattened anteroposteriorly and wide transversely. About 50% of women have gynecoid pelvis or the classic female type of pelvis. It is slightly ovoid or transversely rounded. Android pelvis resembles the male pelvis and may be found in 23% of women. It is heart shaped or angulated. Anthropoid pelvis resembles the pelvis of anthropoid apes and may be found in 24% of women. It is oval and wider anteroposteriorly.

Presentation

Portion of the fetus that enters the pelvic inlet first a. Cephalic (Head) - most common - vertex, military, brow & face b. Breech (buttocks present) - frank, full (complete), and footling - c-section may be required c. Shoulder - fetus in transverse lie; arm, back, abdomen, side could be preent -If fetus does not spontaneously rotate or can be manually turned, need c-section

4 factors that affect fetal circulation during labor

Position, BP, uterine contraction, and cord blood flow

cesarean postoperative

Postoperative a. Monitor vital signs b. Perform a fundal assessment; evaluate incision c. Provide pain relief. d. Encourage turning, coughing, and deep-breathing. e. Encourage ambulation. f. Encourage bonding/attachment with newborn. g. Provide psychological support h. Monitor for signs of infection and bleeding. i. Burning and pain on urination may indicate a bladder infection. j. A tender uterus and foul-smelling lochia may indicate endometritis. k. A productive cough or chills may indicate pneumonia. l. Pain, redness, or edema of an extremity may indicate thrombophlebitis.

A laboring patient reports lower back pain with each contraction and asks why it hurts there. The nurse explains to the patient that which sources contribute to back pain during labor? Select all that apply. Uterine ischemia Pressure on the bladder Distention of the vagina Pulling on the peritoneum Pulling of ligaments of the pelvis

Pressure on the bladder Lower back pain during contractions is likely related to increased pressure on the bladder and the pulling of pelvic structures. This pain is visceral and often refers to the back and legs. Pulling on the peritoneum Lower back pain with contractions is likely related to pressure and pulling of the pelvic structures, including the peritoneum. This pain is visceral and often refers to the back and legs. Correct Pulling of ligaments of the pelvis Lower back pain with contractions is likely related to pressure and pulling of the pelvic structures including the ligaments of the pelvis. This pain is visceral and often refers to the back and legs.

Contractions

Primary powers of labor. They are responsible for dilation and effacement of cervix

Molding

Process whereby the bones of the fetal skull slightly overlap during childbirth.

Valsalva maneuver

Prolonged holding of breath while bearing down (closed-glottis pushing)."

A patient experiences nausea and vomiting during labor. Which medication might the nurse anticipate administering? Fentanyl Naloxone Nalbuphine Promethazine

Promethazine The nurse would anticipate promethazine because it relieves the nausea and vomiting that may occur when opioid drugs are given.

umbilical cord prolapse

Protrusion of the umbilical cord alongside or ahead of the presenting part of the fetus

Prolapse of umbilical cord

Protrusion of umbilical cord in advance of the presenting part.

While caring for a client receiving a nonstress test (NST), the nurse does not observe accelerations in the fetal heart rate (FHR) after 30 minutes of FHR monitoring. What intervention might the nurse perform in order to elicit FHR accelerations? Place the client in a lateral position. Help the client to elevate her legs. Administer oxygen by face mask. Provide vibroacoustic stimulation.

Provide vibroacoustic stimulation. Rationale If fetal heart rate accelerations do not occur after 20 to 30 minutes of continuous FHR monitoring, the nurse can use vibroacoustic stimulation. The client in labor is usually placed in a lateral or semi-Fowler's position to prevent umbilical cord prolapse. Often, the client is assisted to turn to the left side. The nurse administers oxygen via a nonrebreather face mask in case of fetal hypoxemia.

The laboring patient has progressed to 5 cm dilation, and the fetal presenting part is at +1 station. The patient is experiencing contractions every 3 minutes, lasting 60 to 90 seconds, and palpating moderate to strong with soft resting tone. The FHR pattern demonstrates normal characteristics indicative of fetal well-being. The patient is having difficulty relaxing between contractions and reports low back pain. She further states that changing her position is not alleviating the discomfort. The patient and nurse have discussed pain management for labor, and the patient verbalized a desire to labor without epidural anesthesia or analgesia. What is the most appropriate nursing intervention for pain management at this time? Provide, or instruct the support person to provide, counterpressure to the sacral area during contractions. Urge the patient to have an epidural anesthetic because that may provide her the most relief. Administer an enema to relieve the patient's rectal pressure. Instruct the patient to focus on breathing while preparing the room for imminent delivery.

Provide, or instruct the support person to provide, counterpressure to the sacral area during contractions.

A nurse is caring for a patient undergoing an episiotomy repair after birth. Which type of anesthesia does the nurse anticipate? Select all that apply. General anesthesia Epidural anesthesia Pudendal anesthesia Local infiltration anesthesia Combined spinal-epidural anesthesia

Pudendal anesthesia The nurse would anticipate pudendal anesthesia for episiotomy repair. Pudendal blocks anesthetize the lower vagina and part of the perineum. Correct Local infiltration anesthesia The nurse would anticipate local infiltration, which is routinely used for episiotomy repair. Local infiltration anesthesia numbs the immediate area of the episiotomy or laceration.

naloxone indication for respiratory depression

RR less than 10 O2 89% or less administer oxygen through nonrebreather, contact MD

The nurse is monitoring the fetal heart rate (FHR) of a client who is in labor at full term. What measure does the nurse take to obtain the most accurate baseline fetal heart rate? Record or monitor a 10-minute segment of tracing. Include periods of marked variability in the segment. Include episodic changes in the segment of tracing. Obtain at least 5 minutes of interpretable data in the segment.

Record or monitor a 10-minute segment of tracing. Rationale The baseline fetal heart rate is the average rate during a 10-minute segment, and that is why the nurse must obtain a 10-minute segment of tracing to determine the baseline FHR. In order to determine a baseline heart rate, the 10-minute segment must not include periods of marked variability or periodic or episodic changes. The nurse must ensure there are at least 2 minutes of interpretable baseline data in a 10-minute segment of tracing.

Which causes the placenta to separate from the uterine wall? Contractions Rupture of the membranes Reductions in size of the uterine cavity Secretion of prolactin from the pituitary gland

Reductions in size of the uterine cavity After birth, the uterine cavity becomes much smaller, causing the placenta to separate from the uterine wall.

After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: Visceral Referred Somatic Afterpain

Referred As labor progresses the woman often experiences referred pain. It occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and the thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. It results from stretching of the perineal tissues and the pelvic floor and occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

Attitude

Refers to the relationship of the fetal parts to one another. general flexion is the most common type of relationship.

Which reported labor contraction description indicates it is time for a pregnant woman to proceed to the hospital? Mild discomfort felt in the abdomen and pelvis Contractions that subside with increased activity Regular contractions, 5 minutes apart, for 1 hour Irregular contractions, 20 minutes apart, mild in discomfort

Regular contractions, 5 minutes apart, for 1 hour During true labor a consistent pattern of contractions with increasing frequency, duration, and intensity usually develops.

Position

Relationship of assigned area of the presenting part or landmark to the maternal pelvis

Lie

Relationship of the spine of the fetus to the spine of the mother -Longitudinal or vertical ( I ) a.Fetal spine is parallel to mothers pine b. Fetus is in cephalic or breech presentation -Transverse or horizontal ( ---- ) a.Fetal spine is at (R) angle or perpendicular, to mothers pine b.Presenting part is shoulder c.Delivery by c-section is necessary

Which roles does the maternal psyche play in facilitating childbirth? Select all that apply. Fatigue numbs the woman's reaction to pain. Relaxation supports the natural process of labor. Increased anxiety can motivate the woman to push more effectively. Calmness increases a woman's ability to cope with pain during labor. Maternal catecholamines secreted in response to anxiety can increase uterine contractility.

Relaxation supports the natural process of labor. Relaxation techniques, such as slow breathing patterns, augment the natural process of labor. Calmness increases a woman's ability to cope with pain during labor. Marked anxiety, fear, or fatigue decreases a woman's ability to cope with pain in labor.

What does the nurse need to do if she sees Category II FHR tracings?

Requires continued observation and evaluation but are indeterminate

A woman in labor is given fentanyl for pain. Which vital sign is a priority for the nurse to monitor in the newborn infant? Pulse Temperature Blood pressure Respiratory rate

Respiratory rate Opioid analgesics can cause respiratory depression, which is more likely to occur in the newborn than in the mother, and respiratory rate should be monitored.

vaginal exam

Reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured. Perform only when indicated by the status of the woman and her fetus to avoid introduction of microorganisms into the vagina

Latent ("laboring down") phase

Second stage of labor: Is a period of rest and relatively calm. The fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions. The urge to bear down is not strong.

Active pushing (descent) phase

Second stage of labor: The woman has strong urges to bear down as the Ferguson reflex is activated. Fetal station is usually 1+ and the position is anterior.

Abdominal muscle contraction

Secondary powers of labor accomplished when the woman bears down or pushes

During the vaginal examination of a client in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? Cephalic Frank breech Complete breech Shoulder

Shoulder Rationale The presenting part can be defined as that part of the fetus that lies closest to the internal os of the cervix. In the shoulder presentation, the presenting part is the scapula. In a cephalic presentation, the presenting part is usually the occiput. In a breech presentation, the presenting part is the sacrum. The sacrum is the presenting part in a frank breech presentation. The sacrum and feet are the presenting parts in a complete breech presentation.

The nurse is providing care for a client in the first stage of labor. The client's prenatal documentation indicates that the client has scarring on her cervix due to a past STI. What complication might the nurse predict in the client during labor? Ferguson reflex Slow fetal descent Supine hypotension Slow cervical dilation

Slow cervical dilation Rationale The cervical dilation is slowed if a previous vaginal infection has caused scarring of the cervix. This is because the dilation occurs by the drawing upward of the musculofibrous components of the cervix. Ferguson reflex refers to the maternal urge to bear down when the stretch receptors in the posterior vagina release endogenous oxytocin. The administration of epidural analgesia may slow the rate of fetal descent. Supine hypotension occurs due to a drop in hydrostatic pressure.

cervical effacement and dilation

Stage 1 of labor

Vaginal examination steps:

Sterile glove Lubrication Supine (prevent hypotension) Cleanse perineum and vulva, if needed Insert index and middle fingers into vagina Determine: dilation, effacement, and position Determine: presenting part, stationg Determine: status of membranes Determine: characteristics of amniotic fluid Explain findings to woman Document

Which finding does the nurse relate to normal uterine activity in the second stage of labor? Contraction frequency is three in 10 minutes. Contractions peak at 30 to 50 mm Hg. Strength of the contraction is over 80 mm Hg. Relaxation time is 30 seconds or less.

Strength of the contraction is over 80 mm Hg. Rationale During the second stage of labor, the strength of the contractions may increase to over 80 mm Hg. The frequency of contractions is normally up to five contractions every 10 minutes during the second stage of labor. In the first stage, the frequency ranges from two to five contractions in 10 minutes. The contractions peak at 40 to 70 mm Hg in the first stage of labor. The relaxation time is 60 seconds or more during the first stage of labor. This can reduce to 45 seconds or more in the second stage, but should not drop as low as 30 seconds because of risk of fetal distress.

What are the factors that speed up the dilation of the cervix? Select all that apply. Strong uterine contractions Scarring of the cervix Pressure by amniotic fluid Prior infection of the cervix Force by fetal presenting part

Strong uterine contractions Pressure by amniotic fluid Force by fetal presenting part Rationale Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are in turn caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

When assessing intensity and frequency of uterine contractions during the transition phase, which is a typical finding? Strong, every 1½-2 min Mild to moderate, every 5 min Moderate to strong, every 2-3 min Inconsistent in intensity and frequency

Strong, every 1½-2 min During the transition phase, uterine contractions are typically strong and every 1½-2 min.

western

Supine, semi-recumbent, or lithotomy positions are still widely used in __ societies despite evidence that an upright position shortens labor.

The nurse is assisting a client who is prepared to use the paced breathing method. What does the nurse remind the client to do at the beginning of the breathing pattern? Exhale a deep breath. Take a deep relaxing breath. Take 32 breaths per minute. Take three breaths per minute.

Take a deep relaxing breath. Rationale The client must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The client must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The client must take six to eight breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the client takes shallow, fast breaths, about 32 to 40 per minute.

Nitrazine test

Test to determine if membranes have ruptured by assessing pH of the fluid."

With regard to primary and secondary powers, the maternity nurse should understand what? That primary powers are responsible for effacement and dilation of the cervix That effacement generally is well ahead of dilation in women giving birth for the first time; they are less together in subsequent pregnancies That scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation That pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs

That primary powers are responsible for effacement and dilation of the cervix Rationale The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-time mothers; they are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

first stage of labor

The 1st stage of labor begins with the onset of regular uterine contractions and ends with full cervical effacement and dilation.

The health care provider applies pressure to the fetal chin though the perineum, while applying pressure to the occiput of the fetal head. What is the aforementioned action called? Sellick Maneuver Valsalva Maneuver Leopold's Maneuver The Ritgen Maneuver

The Ritgen Maneuver The Ritgen Maneuver controls the exit of the fetal head so that it is born gradually rather than popping out, minimizing trauma to the maternal tissues.

Which is the nurse assessing when evaluating the frequency of contractions? The strength of the contractions The length of each contraction from beginning to end The period between the end of one contraction and the beginning of the next The average time that elapses from the beginning of one contraction to the beginning of the next

The average time that elapses from the beginning of one contraction to the beginning of the next Frequency is the period from the beginning of one uterine contraction to the beginning of the next.

The nurse is aware that which conditions must be met to apply a fetal scalp monitor? Select all that apply. The mother should not be in labor. The fetus should have a lot of scalp hair. The cervix should be at least 2 cm dilated. The mother's membranes must have ruptured. The scalp electrode should be applied to the fontanels.

The cervix should be at least 2 cm dilated. The fetal scalp monitor can be used once the mother's cervix has dilated to at least 2 cm. Correct The mother's membranes must have ruptured. The fetal scalp monitor can be used once the mother's membranes have ruptured.

The nurse is caring for a Native-American client during labor. What does the nurse keep in mind about the client's cultural approach to pain? The client may exhibit reactions to pain. The client may be vocal in response to pain. The client may use remedies from indigenous plants. The client may express pain vocally late in labor.

The client may use remedies from indigenous plants. Rationale The Native-American client may use medications or remedies made from medicinal plants. They are often stoic in response to labor pain. Hispanic clients may be stoic until late in labor, when they may become vocal and request pain relief. Chinese clients may not exhibit reactions to pain. Arabian or Middle Eastern clients may be vocal in response to labor pain and request medication for pain relief.

The nurse notes accelerations on the fetal heart rate pattern. Which is the nurse able to determine given this assessment? The fetus has a cord prolapse. The mother requires oxygen therapy. Immediate nursing intervention is necessary. The fetus has an active central nervous system.

The fetus has an active central nervous system. Accelerations are usually a reassuring sign that the fetus has a responsive CNS and is not in acidosis.

The nurse is preparing for an amnioinfusion. The nurse knows that which situation may have caused the need for this intervention? The mother has diabetes. The fetal heart rate (FHR) is 140 bpm. The mother's blood pressure has dropped. The fetus has experienced an intrauterine stress.

The fetus has experienced an intrauterine stress. When stressed, the fetus can release meconium and risk aspiration. The amnioinfusion would infuse fluids to clear the meconium.

Passenger

The fetus, membranes, and placenta

Which is included when teaching the patient and their birthing partner about expected maternal behaviors during the transition phase of labor? Select all that apply. The mother may become easily irritated. The mother is typically sociable and excited. The mother typically feels excited and relieved. The mother typically becomes more inwardly focused. The mother may experience vomiting feeling of losing control.

The mother may become easily irritated. The mother's irritation may increase during the transition phase of labor. The mother typically becomes more inwardly focused. The mother typically becomes more inwardly focused during the transition phase of labor. Correct The mother may experience vomiting feeling of losing control. The mother may experience a feeling of losing control during the transition phase of labor.

Passageway

The mother's rigid bony pelvis and soft tissues of cervix, pelvic floor, vagina, and introitus (external opening to the vagina)

lightening

The movement of the fetus down into the pelvis late in pregnancy. less pressure below ribcage breathe easy more bladder pressure

cervix

The only certain objective sign that the second stage of labor has begun is the inability to feel the __ during vaginal examination, indicating that the cervix is fully dilated and effaced. Women will feel the urge to push or have bowel movement.

A client who is full term has experienced breathlessness throughout the pregnancy. The client reports a sudden ease in breathing, but also a frequent urge to urinate. What does the nurse interpret from these findings? The fetus has a vertex presentation. The client's cervix is dilated and effaced. The client has a rupture of fetal membranes The presenting part of fetus is engaged in the pelvis.

The presenting part of fetus is engaged in the pelvis. Rationale When the fetus descends down and engages in the pelvis, the diaphragm may get sufficient space to contract and relax, making it easier for the client to breathe. The lower position of the fetus in the uterus may put additional pressure on the bladder, however, increasing the frequency of urination. Based on the client's signs, it can be inferred that the fetus is engaged in the pelvis. However, the presenting part of the fetus cannot be determined by the client's signs. The presenting part of the fetus can be determined by palpation. When there is rupture of fetal membranes, there is dribbling of amniotic fluid. Cervical dilatation and effacement is indicated by a bloody cervical show.

External Rotation

The shoulders externally rotate after the head emerges and restitution occurs, so that the shoulders are in the anteroposterior diameter of the pelvis.

Presenting part

The specific fetal structure lying nearest to the cervix

environment effect on pain response

The woman's _____ includes the individuals present (e.g. how they communicate; their philosophy of care, including the belief in the value of nonpharmacologic pain relief measures; practice policies; and quality of support) and the physical space in which the labor occurs. Women who are in a supportive environment feel more in control and therefore are more likely to have a better labor and birth experience. The environment should be safe and private, allowing a woman to feel free to be herself as she tries out different comfort measures. Stimuli such as light, noise, and temperature should be adjusted according to her preferences. The environment should space for movement, position changes, ambulation and equipment such as birthing balls. Comfortable chairs, tubs, and showers should be readily available to facilitate participation in a variety of nonpharmacologic pain relief measures.

The nurse is caring for a client who is in the third trimester of pregnancy. The client reports pain in the pelvic joints. What does the nurse recognize as the cause of the pain? There is relaxation of the pelvic joints. There is decreased mobility of the ligaments. The joint of the symphysis pubis is narrowing. The pelvis may not support vaginal birth.

There is relaxation of the pelvic joints. Rationale In the third trimester of pregnancy, the pelvic joints relax, leading to pain. There is increased mobility of the pelvic joints and ligaments as a result of hormonal influences. Widening of the joint of the symphysis pubis and the resulting instability may cause pain in any or all of the pelvic joints. Pain in the pelvic joints does not indicate that the pelvis may not support vaginal birth. A heart shaped android pelvis may not support spontaneous vaginal birth.

A laboring patient places a cool, dark compress over her forehead during labor. This is an example of which relaxation technique? Massage Acupressure Hydrotherapy Thermal stimulation

Thermal stimulation The laboring woman may place it on her head, throat, or abdomen, particularly if she feels overheated. Another example of thermal stimulation is a relaxing warm shower or bath.

In which stage of labor does the nurse expect the placenta to be expelled? First Second Third Fourth

Third Rationale The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

The nurse encourages a client to experiment with various positions during labor. What is the rationale behind this instruction? To enhance gas exchange in the fetus To assist downward movement of the fetus To reduce anxiety and fear in the client To prevent cervical and vaginal lacerations

To assist downward movement of the fetus Rationale The client is encouraged to experiment with various positions during the process of labor to help the labor progress and to remain comfortable. Certain maternal positions help improve placental sufficiency more than others. These help hasten the process of vaginal delivery.To enhance gas exchange in the fetus, the client is asked to take deep, cleansing breaths. Experimenting with various positions does not aid in effective breathing. Anxiety and fear are common during the process of labor, but this intervention may not reduce anxiety in the client. The client is made to feel comfortable by minimizing distractions during labor. Changing of positions may not help in preventing lacerations sustained during the childbirth process.

infection

To limit the chances of __, limit the number of vaginal exams and assess maternal temperature and vaginal discharge frequently (q 2 hours)

While caring for a client in labor, the nurse cleans the client's teeth with an ice-cold wet washcloth. What is the rationale behind the intervention? Select all that apply. To aid in relaxation To refresh the mouth To reduce the feeling of thirst To reduce the risk of infection To counteract dry mouth

To refresh the mouth To reduce the feeling of thirst To counteract dry mouth Rationale A client in labor may not be able to take care of her oral hygiene. Therefore, the nurse should use an ice-cold wet washcloth to clean the client's teeth to maintain oral hygiene and refresh the mouth. The pregnant client may feel thirsty due to active labor. Cleaning the client's teeth with an ice-cold wet washcloth may moisten the oral cavity and reduce the feeling of thirst. This intervention also prevents the oral cavity form becoming dry. Cleaning the teeth does not provide relaxation during labor. The nurse may teach the client deep breathing exercises to promote relaxation during labor. Cleaning the teeth does not reduce infections during labor; however, regular handwashing may decrease the risk of infections.

Which techniques does the nurse use to comfort the pregnant client in the first stage of labor? Select all that apply. Touch Effleurage Acupuncture Hyperesthesia Counterpressure

Touch Effleurage Counterpressure Rationale Touch refers to act of holding the client's hand, stroking her body, or embracing her. It helps communicate care, reassurance, and concern. The nurse implements effleurage or light stroking of the abdomen in rhythm with the client's breathing during contractions in the first stage of labor. It helps distract the client from the perception of pain. Counterpressure is the application of steady pressure to the sacral area with a firm object or the fist or heel of the hand. It helps the client cope with the sensations of internal pressure and pain in the lower back. Acupuncture is not performed by the nurse but is done by a trained, certified therapist. The therapist inserts fine needles into specific areas of the client's body to restore energy and decrease pain. Hyperesthesia refers to the state of hypersensitivity to touch, which reduces the effect of nonpharmacologic measures of pain relief.

Lithotomy"

Traditional labor position in which the woman lies on her back with her legs raised in stirrups." "9. Lithotomy"

Doula"

Trained and experienced female labor attendant who provides a continuous one-on-one caring presence throughout the labor and birth of the woman she is attending."

Which device can be used as a noninvasive way to assess the fetal heart rate in a client whose membranes are not ruptured? Tocotransducer Spiral electrode Ultrasound transducer Intrauterine pressure catheter (IUPC)

Ultrasound transducer Rationale An ultrasound transducer is used to assess the FHR by an external mode of electronic fetal monitoring. It does not require membrane rupture and cervical dilation. A tocotransducer can be used to assess the uterine activity (UA) in a pregnant client whose cervix is not sufficiently dilated, but does not assess the FHR. A spiral electrode is used in the internal mode of electronic fetal monitoring to assess the FHR. It can be used only when membranes are ruptured and the cervix is dilated during intrapartum period. IUPC is used to assess the UA in internal mode. It can be used only when membranes are ruptured and the cervix is dilated during the intrapartum period.

After observing the reports of umbilical cord acid-base determination test, the nurse informs the client that the newborn's condition is normal. Which value indicates the normal condition of the newborn? Umbilical artery: pH -7.1, Pco 2 -50 mm Hg, Po 2 -20 mm Hg Umbilical artery: pH -7.3, Pco 2 -40 mm Hg, Po 2 -10 mm Hg Umbilical artery: pH -7.4, Pco 2 -52 mm Hg, Po 2 -27 mm Hg Umbilical artery: pH -7.3, Pco 2 -45 mm Hg, Po 2 -25 mm Hg

Umbilical artery: pH -7.3, Pco 2 -45 mm Hg, Po 2 -25 mm Hg Rationale In umbilical cord acid-base stimulation method, arterial values indicate the condition of the newborn. Arterial blood pH of 7.2 to 7.3, carbon dioxide pressure (Pco 2) value of 45 to 55 mm Hg, and oxygen pressure (Po 2) value of 15 to 25 mm Hg approximately indicates the normal fetal condition. Therefore pH: 7.3, Pco 2 -45, Po 2 -25 values are representing the normal fetal condition. Arterial blood pH -7.1, Pco 2 -50 mm Hg, Po 2 -20 mm Hg indicate that the fetus may have respiratory acidosis. Arterial blood pH -7.4 is indicative of fetal alkalosis.

What should the nurse assess while reviewing the umbilical cord acid-base report of a client in order to determine placental function? Umbilical vein report Umbilical artery report Amniotic fluid concentration Blood glucose concentration

Umbilical vein report Rationale Umbilical acid base determination helps to determine the immediate condition of the newborn after birth. The nurse should check the umbilical vein report to determine the placental functioning of the client. The placental function would help to assess the nutritional status of the newborn baby. The umbilical artery report is used to determine the physiologic functioning of the newborn. Amniotic fluid concentrations are monitored during labor, but not after birth. Blood glucose levels in the fetus are not assessed with the umbilical cord test.

The nurse has administered lorazepam (Ativan) along with opioids to a client to relieve labor pain. Which sign in the client indicates a need for metoclopramide (Reglan)? Central nervous system (CNS) depression Nausea and vomiting Unrelieved pain Decreased uterine contractions

Unrelieved pain Rationale Metoclopramide (Reglan) is an antiemetic, which may potentiate the effect of the analgesic. Naloxone (Narcan) is an opioid antagonist that helps relieve central nervous system (CNS) depression in a client. Lorazepam (Ativan) reduces nausea and vomiting in the client when administered along with an opioid. Opioids inhibit uterine contractions, so they are not administered until labor is well established.

Slow-Paced Breathing

Used for as long as possible during labor. Promotes relaxation

Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will affect fetal circulation during labor? Select all that apply. Fetal position Uterine contractions Blood pressure Umbilical cord blood flow Fetal sex

Uterine contractions Blood pressure Umbilical cord blood flow Rationale Uterine contractions during labor tend to decrease circulation and subsequent perfusion. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Maternal blood pressure is likely to have a significant effect on fetal circulation. Compression of the cord and reduction of umbilical blood flow affect fetal circulation. Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow. The fetal sex does not affect umbilical blood flow.

Powers

Uterine contractions 1. Forces acting to expel the fetus 2. Effacement shortening and thinning of cervix during the 1st stage of labor 3. Dilation- enlargement of cervical os and cervical canal during the 1st sage of labor 4. Pushing efforts of mother during 2nd stage

The nurse administers an amnioinfusion to a pregnant client according to the primary health care provider's (PHP) instructions. What is the reason behind the PHP's instructions? Late decelerations Early decelerations Variable decelerations Prolonged decelerations

Variable decelerations Rationale Variable decelerations in the FHR are observed when the umbilical cord is compressed. An amnioinfusion refers to the infusion of isotonic fluid into the uterine cavity when the amniotic fluid levels are decreased. This intervention is usually done for the prevention of umbilical cord compression. Late decelerations are observed when infections or elevated uterine contractions (UCs) are seen in a patient. This condition will be reversed by maintaining IV solution, but aminoinfusion is not administered. Early deceleration in the FHR is a normal sign that does not require any intervention. Prolonged deceleration of the FHR occurs when there is marked reduction of fetal oxygen supply.

Fetal bradycardia is most common during: Maternal hyperthyroidism. Fetal anemia. Viral infection. Tocolytic treatment using ritodrine.

Viral infection. Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, viral infections such as cytomegalovirus (CMV), maternal hypothermia, and maternal hypothermia. Maternal hyperthyroidism, fetal anemia, and tocolytic treatment using ritodrine will most likely result in fetal tachycardia.

Under which circumstance would a nurse not perform a vaginal examination on a patient in labor? An admission to the hospital at the start of labor When accelerations of the fetal heart rate (FHR) are noted On maternal perception of perineal pressure or the urge to bear down When membranes rupture

When accelerations of the fetal heart rate (FHR) are noted An accelerated FHR is a positive sign not requiring vaginal examination; variable decelerations, however, merit a vaginal examination. Vaginal examination should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is another appropriate time to perform a vaginal examination, as is after rupture of membranes (ROM). The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM.

When is the best time to determine the station of the presenting part in a pregnant client? When the labor begins A week before the labor During the fourth stage of labor At the end of the third stage of labor

When the labor begins Rationale The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Birth is imminent when the presenting part is at +4 cm to +5 cm below the spine. A week before the labor is too early to determine the station, because fetal descent has usually not begun. The delivery of the placenta occurs in the fourth stage of labor. Therefore, the birth process is already complete by this stage. The third stage involves the birth of the infant and ends with the expulsion of the placenta. Therefore, it is ineffective to determine the station at that point.

Considerations when taking care of a patient with a history of sexual abuse:

Woman feels loss of control Confined and restrained Associate the sensations she is experiencing with the process of birth and not with her past Explain all procedures Receive permission before touching the patient Accept extreme reactions Limit procedures that invade her body Choose a person to provide support

hands and knees

__ position during contractions or a lateral position on the same side as the fetal spine and also recommended to facilitate the rotation of the fetal occiput from a posterior to an anterior position, as gravity pulls the fetal back forward.

non-English speaking

__ women often feel a complete loss of control over their situation if no health care provider is present who speaks their language Ideally, i bilingual or bicultural nurse will care for the woman

amniotomy

artificial rupture of membranes (AROM)

periodic changes

changes from baseline pattersn in FHR that occur with uterine contractions

episodic changes

changes in FHR from baseline that are not associated with uterine contraction

acupuncture

insertion of fine needles into specific areas of the body to restore the flow of qi (energy) and to decrease pain

epidural block effects of newborn

no lasting

bradycardia

persistent (10 minutes or longer) baseline FHR below 110 beats/min

Chinese women in labor

women may not exhibit reactions to pain, although exhibiting pain during childbirth is acceptable. They consider accepting something when it is first offered as impolite; therefore, pain interventions must be offered more than once. Acupuncture may be used for pain relief.

Native American

women may use medications or remedies made from indigenous plants. They are often stoic in response to labor pain.

maternal opioid abstinence syndrome

yawning, rhinnorhea, sweating, tearing, dialation of pupils anorexia irritability, restlessness generalized anxiety tremors chills and hot flushes goose bumps violent sneezing weakness, fatigue and drowziness nausea and vomiting diarrhea and abdominal cramps bone and muscle pain, muscle spasm, kicking movements

The nurse educator is teaching a group of student nurses about the manifestations of true labor. Which statement by a student about true labor indicates effective learning? "The fetus is usually not engaged in the pelvis." "The cervix is often soft and is felt in the posterior position." "Contractions become more intense with walking." "Contractions are felt above the navel."

"Contractions become more intense with walking." Rationale True labor is associated with painful contractions that become more intense as the client walks. These contractions indicate true labor. The fetus is engaged in the pelvis during true labor. When a client is in true labor, the cervix is becomes soft and is placed anteriorly. The fetus shows progressive change and is felt in the anterior position during true labor. For most women, the contractions of true labor are not felt above the navel but at the lower portion of the abdomen.

Which of the following responses is the primary rationale for providing general information as well as breathing and relaxation exercises in childbirth education classes? 1. Mothers who are doing breathing exercises during labor will refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear tension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective? a. Dilation of the cervix b. Descent of the fetus to -2 station c. Rupture of the amniotic membranes d. Increase in bloody show

ANS: A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor.

Part of the nurse's role is assisting with pushing and positioning. Which guidance should the nurse provide to her client in active labor? a. Encourage the woman's cooperation in avoiding the supine position. b. Advise the woman to avoid the semi-Fowler position. c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response. d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push.

ANS: A The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, allowing air to escape during the push.

A laboring woman is reclining in the supine position. What is the most appropriate nursing action at this time? a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether fetal tachycardia is present.

ANS: A The woman's supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, then fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. Blood pressure readings may be obtained when the client is in the appropriate and safest position.

Conscious relaxation is associated with which method of childbirth preparation? a. Grantly Dick-Read childbirth method b. Lamaze method c. Bradley method d. Psychoprophylactic method

ANS: A With the Grantly Dick-Read method, women are taught to consciously and progressively relax different muscle groups throughout the body until a high degree of skill at relaxation is achieved. The Lamaze method combines controlled muscular relaxation with breathing techniques. The Bradley method advocates natural labor, without any form of anesthesia or analgesia, assisted by a husband-coach and using breathing techniques for labor. The psychoprophylactic method is another name for the Lamaze method.

Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. Which items might this plan include? (Select all that apply.) a. Presence of companions b. Clothing to be worn c. Care and handling of the newborn d. Medical interventions e. Date of delivery

ANS: A, B, C, D The presence of companions, clothing to be worn, care and handling of the newborn, medical interventions, and environmental modifications all might be included in the couple's birth plan. Other items include the presence of nonessential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements. The expected date of delivery would not be part of a birth plan unless the client is scheduled for an elective cesarean birth.

A woman who is gravida 3 para 2 arrives on the intrapartum unit. What is the most important nursing assessment at this time? a. Contraction pattern, amount of discomfort, and pregnancy history b. FHR, maternal vital signs, and the woman's nearness to birth c. Identification of ruptured membranes, woman's gravida and para, and her support person d. Last food intake, when labor began, and cultural practices the couple desires

ANS: B All options describe relevant intrapartum nursing assessments; however, this focused assessment has a priority. If the maternal and fetal conditions are normal and birth is not imminent, then other assessments can be performed in an unhurried manner; these include: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices.

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. Admission to the hospital at the start of labor b. When accelerations of the FHR are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

ANS: B An accelerated FHR is a positive sign; therefore, a vaginal examination would not be necessary. A vaginal examination should be performed when the woman is admitted to the hospital, when she perceives perineal pressure or the urge to bear down, when her membranes rupture, when a significant change in her uterine activity has occurred, or when variable decelerations of the FHR are noted.

Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct? a. Even mild anxiety must be treated. b. Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can sufficiently build to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

During labor a fetus displays an average FHR of 135 beats per minute over a 10-minute period. Which statement best describes the status of this fetus? a. Bradycardia b. Normal baseline heart rate c. Tachycardia d. Hypoxia

ANS: B The baseline FHR is measured over 10 minutes; a normal range is 110 to 160 beats per minute. Bradycardia is a FHR less than 110 beats per minute for 10 minutes or longer. Tachycardia is a FHR higher than 160 beats per minutes for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of hypoxia exists with a baseline FHR in the normal range.

The nurse should be aware of what important information regarding systemic analgesics administered during labor? a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular (IM) administration is preferred over IV administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

ANS: B The effects of analgesics depend on the specific drug administered, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in a decrease in the use of an analgesic.

What is the rationale for the use of a blood patch after spinal anesthesia? a. Hypotension b. Headache c. Neonatal respiratory depression d. Loss of movement

ANS: B The subarachnoid block may cause a postspinal headache resulting from the loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop the leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

Through a vaginal examination, the nurse determines that a woman is 4 cm dilated. The external fetal monitor shows uterine contractions every to 4 minutes. The nurse reports this as what stage of labor? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase

ANS: B This maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of "laboring down."

HIV

Any woman whose __ status is undocumented at the time of labor should be screened (unless opted out)

Which of the following statements is not used to describe a characteristic of a uterine contraction? Frequency (how often contractions occur) Intensity (the strength of the contraction at its peak) Resting tone (the tension in the uterine muscle) Appearance (shape and height)

Appearance (shape and height) Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.

Meconium staining

Appearance of fetal intestinal contents in the amniotic fluid, giving it a greenish color."

Fundal pressure

Application of a gentle yet steady force with hands pressed against the uterus

The nurse providing care for the laboring woman understands that accelerations with fetal movement: Are reassuring. Are caused by umbilical cord compression. Warrant close observation. Are caused by uteroplacental insufficiency.

Are reassuring. Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being; they do not warrant close observation. Umbilical cord compression results in variable decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR.

The nurse sees that the patient is having a contraction, but the monitor is not detecting the contraction with the tocodynamometer. Which action would the nurse take? Reposition the mother on her side. Apply oxygen to the laboring patient. Call the health care provider immediately. Assess and reposition the tocodynamometer so it is secure

Assess and reposition the tocodynamometer so it is secure. The nurse would first assess the tocodynamometer to see if it is secure and placed correctly to monitor the contractions. To determine placement, the nurse should palpate the abdomen to identify the area where the contraction is strongest.

Interval

_______________________ Period of rest between contractions."

Duration "

_______________________ The time that elapses between the onset and the end of a contraction."

Tocolysis

relaxation of the uterus that can be achieved throught the admin of drugs that inhibit uterine contractions. the most commonly used for this purpose is terbutaline.

hypnosis

relaxation similar to daydreaming or meditation, state of focused concentration

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. Which instruction best describes these measures? a. Encouraging the woman to try various upright positions, including squatting and standing b. Telling the woman to start pushing as soon as her cervix is fully dilated c. Continuing an epidural anesthetic so pain is reduced and the woman can relax d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

ANS: A Both upright and squatting positions may enhance the progress of fetal descent. Many factors dictate when a woman should begin pushing. Complete cervical dilation is necessary, but complete dilation is only one factor. If the fetal head is still in a higher pelvic station, then the physician or midwife may allow the woman to "labor down" if the woman is able (allowing more time for fetal descent and thereby reducing the amount of pushing needed). The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding her breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia.

Which description of the four stages of labor is correct for both the definition and the duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third stage: active pushing to birth; 20 minutes (multiparous woman), 50 minutes (nulliparous woman) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies full dilation can take up to 20 hours. The second stage of labor extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage of labor extends from birth to the expulsion of the placenta and usually takes a few minutes. The fourth stage begins after the expulsion of the placenta and lasts until homeostasis is reestablished (approximately 2 hours).

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the FHR for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse's first priority? a. Change the woman's position. b. Notify the health care provider. c. Assist with amnioinfusion d. Insert a scalp electrode.

ANS: A Late FHR decelerations may be caused by maternal supine hypotension syndrome. These decelerations are usually corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, then the nurse should continue with subsequent intrauterine resuscitation measures and notify the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely will reveal variable decelerations. Although a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it is not a nursing intervention that will alleviate late decelerations nor is it the nurse's first priority.

Which nursing intervention would result in an increase in maternal cardiac output? a. Change in position b. Oxytocin administration c. Regional anesthesia d. IV analgesic

ANS: A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This position reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

What are the legal responsibilities of the perinatal nurses? a. Correctly interpreting FHR patterns, initiating appropriate nursing interventions, and documenting the outcomes b. Greeting the client on arrival, assessing her status, and starting an IV line c. Applying the external fetal monitor and notifying the health care provider d. Ensuring that the woman is comfortable

ANS: A Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients and falls within the registered nurse's scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

Which statement best describes a normal uterine activity pattern in labor? a. Contractions every 2 to 5 minutes b. Contractions lasting approximately 2 minutes c. Contractions approximately 1 minute apart d. Contraction intensity of approximately 500 mm Hg with relaxation at 50 mm Hg

ANS: A Overall contraction frequency generally ranges from two to five contractions per 10 minutes of labor, with lower frequencies during the first stage and higher frequencies observed during the second stage. Contraction duration remains fairly stable throughout the first and second stages, ranging from 45 to 80 seconds, generally not exceeding 90 seconds. Contractions 1 minute apart are occurring too often and would be considered an abnormal labor pattern. The intensity of uterine contractions generally ranges from 25 to 50 mm Hg in the first stage of labor and may rise to more than 80 mm Hg in the second stage.

The nurse should be cognizant of which physiologic effect of pain? a. Predominant pain of the first stage of labor is visceral pain that is located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort experienced between contractions. c. Somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.

ANS: A Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.

What is the most critical nursing action in caring for the newborn immediately after the birth? a. Keeping the airway clear b. Fostering parent-newborn attachment c. Drying the newborn and wrapping the infant in a blanket d. Administering eye drops and vitamin K

ANS: A The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, to support respiratory effort, and to prevent cold stress by drying the newborn and covering him or her with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn's physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the newborn to the partner or to the mother of the infant.

Which stage of labor varies the most in length? a. First b. Second c. Third d. Fourth

ANS: A The first stage of labor is considered to last from the onset of regular uterine contractions to the full dilation of the cervix. The first stage is significantly longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts approximately 2 hours after the delivery of the placenta.

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position? a. Occiput of the fetus is in a posterior position. b. Fetus is at or above the ischial spines. c. Fetus is in a vertex presentation. d. Membranes have ruptured.

ANS: A The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position. Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases, this urge is felt before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred. No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions. The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.

The nurse should be aware of which information related to a woman's intake and output during labor? a. Traditionally, restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids are usually necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will quickly follow.

ANS: A Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. The routine use of an enema is, at best, ineffective and may be harmful. Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a nulliparous woman.

While developing an intrapartum care plan for the client in early labor, which psychosocial factors would the nurse recognize upon the client's pain experience? (Select all that apply.) a. Culture b. Anxiety and fear c. Previous experiences with pain d. Intervention of caregivers e. Support systems

ANS: A, B, C, E Culture: A woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify the sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: Fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, IV lines).

At least five factors affect the process of labor and birth. These are easily remembered as the five Ps. Which factors are included in this process? (Select all that apply.) a. Passenger b. Passageway c. Powers d. Pressure e. Psychologic response

ANS: A, B, C, E The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. Pressure is not one of the five Ps.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's ideal response? a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You can have an epidural. You won't feel anything."

ANS: B "It's normal to be anxious about labor. Let's discuss what makes you afraid" is a statement that allows the woman to share her concerns with the nurse and is a therapeutic communication tool. "Don't worry about it. You'll do fine" negates the woman's fears and is not therapeutic. "Labor is scary to think about, but the actual experience isn't" negates the woman's fears and offers a false sense of security. To suggest that every woman can have an epidural is untrue. A number of criteria must be met before an epidural is considered. Furthermore, many women still experience the feeling of pressure with an epidural.

What is the correct terminology for the nerve block that provides anesthesia to the lower vagina and perineum? a. Epidural b. Pudendal c. Local d. Spinal block

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and the use of low forceps, if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

What three measures should the nurse implement to provide intrauterine resuscitation? a. Call the provider, reposition the mother, and perform a vaginal examination. b. Turn the client onto her side, provide oxygen (O2) via face mask, and increase intravenous (IV) fluids. c. Administer O2 to the mother, increase IV fluids, and notify the health care provider. d. Perform a vaginal examination, reposition the mother, and provide O2 via face mask.

ANS: B Basic interventions for the management of any abnormal FHR pattern include administering O2 via a nonrebreather face mask at a rate of 8 to 10 L/min, assisting the woman onto a side-lying (lateral) position, and increasing blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and to increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. If these interventions do not quickly resolve the abnormal FHR issue, then the primary provider should be immediately notified.

Developing a realistic birth plan with the pregnant woman regarding her care is important for the nurse. How would the nurse explain the major advantage of nonpharmacologic pain management? a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman will remain fully alert at all times. d. Labor will likely be more rapid.

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. However, pain relief is lessened with nonpharmacologic pain management during childbirth. Although the woman's alertness is not altered by medication, the increase in pain may decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.

According to professional standards (the Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2007), which action cannot be performed by the nonanesthetist registered nurse who is caring for a woman with epidural anesthesia? a. Monitoring the status of the woman and fetus b. Initiating epidural anesthesia c. Replacing empty infusion bags with the same medication and concentrate d. Stopping the infusion, and initiating emergency measures

ANS: B Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion. The nonanesthetist nurse is permitted to monitor the status of the woman, the fetus, and the progress of labor. Replacement of the empty infusion bags or syringes with the same medication and concentration is permitted. If the need arises, the nurse may stop the infusion, initiate emergency measures, and remove the catheter if properly educated to do so. Complications can require immediate interventions. Nurses must be prepared to provide safe and effective care during an emergency situation.

What should the laboring client who receives an opioid antagonist be told to expect? a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

ANS: B Opioid antagonists such as naloxone (Narcan) promptly reverse the CNS-depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if the labor is more rapid than expected and the birth is anticipated when the opioid is at its peak effect. The woman should be told that the pain that was relieved by the opioid analgesic will return with the administration of the opioid antagonist. Her pain level will increase rather than decrease. Opioid antagonists have no effect on anxiety levels. They are primarily administered to reverse the excessive CNS depression in the mother, newborn, or both. An opioid antagonist (e.g., naloxone) has no effect on the mother's urge or ability to push. The practice of giving lower doses of IV opioids has reduced the incidence and severity of opioid-induced CNS depression; therefore, opioid antagonists are used less frequently.

What is the rationale for the administration of an oxytocic (e.g., Pitocin, Methergine) after expulsion of the placenta? a. To relieve pain b. To stimulate uterine contraction c. To prevent infection d. To facilitate rest and relaxation

ANS: B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain, do not prevent infection, and do not facilitate rest and relaxation.

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement regarding this procedure is correct? a. The application of nitrous oxide gas is not often used anymore. b. An inhalation of gas is likely to be used in the second stage of labor, not during the first stage. c. An application of nitrous oxide gas is administered for pain relief. d. The application of gas is a prelude to a cesarean birth.

ANS: C A mixture of nitrous oxide with oxygen in a low concentration can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief. This procedure is still commonly used in Canada and in the United Kingdom. Nitrous oxide inhaled in a low concentration will reduce but not eliminate pain during the first and second stages of labor. Nitrous oxide inhalation is not generally used before a caesarean birth. Nitrous oxide does not appear to depress uterine contractions or cause adverse reactions in the newborn.

Which statement is not an expected outcome for the client who attends a reputable childbirth preparation program? a. Childbirth preparation programs increase the woman's sense of control. b. Childbirth preparation programs prepare a support person to help during labor. c. Childbirth preparation programs guarantee a pain-free childbirth. d. Childbirth preparation programs teach distraction techniques.

ANS: C All methods try to increase a woman's sense of control, prepare a support person, and train the woman in physical conditioning, which includes breathing techniques. These programs cannot, and reputable ones do not, promise a pain-free childbirth. Increasing a woman's sense of control is the goal of all childbirth preparation methods. Preparing a support person to help in labor is a vitally important component of any childbirth education program. The coach may learn how to touch a woman's body to detect tense and contracted muscles. The woman then learns how to relax in response to the gentle stroking by the coach. Distraction techniques are a form of care that are effective to some degree in relieving labor pain and are taught in many childbirth programs. These distractions include imagery, feedback relaxation, and attention-focusing behaviors.

A woman's position is an important component of the labor progress. Which guidance is important for the nurse to provide to the laboring client? a. The supine position, which is commonly used in the United States, increases blood flow. b. The laboring client positioned on her hands and knees ("all fours" position) is hard on the woman's back. c. Frequent changes in position help relieve fatigue and increase the comfort of the laboring client. d. In a sitting or squatting position, abdominal muscles of the laboring client will have to work harder.

ANS: C Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The "all fours" position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions.

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief? a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

ANS: C Hispanic women may be stoic early in labor but more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start; they may prefer pain medications. African-American women may openly express pain; the use of medications for pain is more likely to vary with the individual.

Which information related to a prolonged deceleration is important for the labor nurse to understand? a. Prolonged decelerations present a continuing pattern of benign decelerations that do not require intervention. b. Prolonged decelerations constitute a baseline change when they last longer than 5 minutes. c. A disruption to the fetal oxygen supply causes prolonged decelerations. d. Prolonged decelerations require the customary fetal monitoring by the nurse.

ANS: C Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, then the fetal cardiac tissue, itself, will become hypoxic, resulting in direct myocardial depression of the FHR. Prolonged decelerations can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting longer than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in the FHR of at least 15 beats per minute below the baseline and lasting longer than 2 minutes but shorter than 10 minutes. Nurses should immediately notify the physician or nurse-midwife and initiate appropriate treatment of abnormal patterns when they see prolonged decelerations.

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor? a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

ANS: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

Which description of the phases of the second stage of labor is most accurate? a. Latent phase: Feeling sleepy; fetal station 2+ to 4+; duration of 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions; Ferguson reflux activated; duration of 5 to 15 minutes c. Descent phase: Significant increase in contractions; Ferguson reflux activated; average duration varies d. Transitional phase: Woman "laboring down"; fetal station 0; duration of 15 minutes

ANS: C The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull or "laboring down" period at the beginning of the second stage and lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next? a. Immediately notify the woman's primary health care provider. b. Prepare to administer an oxytocic to stimulate uterine activity. c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. d. Prepare the woman for the onset of the second stage of labor.

ANS: C The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the client's medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips b. Determining the frequency by timing from the end of one contraction to the end of the next contraction c. Evaluating the intensity by pressing the fingertips into the uterine fundus d. Assessing uterine contractions every 30 minutes throughout the first stage of labor

ANS: C The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.

A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior? a. A nulliparous woman will experience a strong urge to bear down. b. Perineal bulging will show. c. A nulliparous woman will remain quiet with her eyes closed between contractions. d. The amount of bright red bloody show will increase.

ANS: C The woman is able to relax and close her eyes between contractions as the fetus passively descends. The woman may be very quiet during this phase. During the latent phase of the second stage of labor, the urge to bear down is often absent or only slight during the acme of the contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

Which definition of an acceleration in the fetal heart rate (FHR) is accurate? a. FHR accelerations are indications of fetal well-being when they are periodic. b. FHR accelerations are greater and longer in preterm gestations. c. FHR accelerations are usually observed with breech presentations when they are episodic. d. An acceleration in the FHR presents a visually apparent and abrupt peak.

ANS: D Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in the FHR above the baseline rate. Periodic accelerations occur with uterine contractions and are usually observed with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Preterm accelerations peak at 10 beats per minute above the baseline and last for at least 10 seconds.

The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware of and prepared for the greatest risk of administering general anesthesia to the client. What is this risk? a. Respiratory depression b. Uterine relaxation c. Inadequate muscle relaxation d. Aspiration of stomach contents

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia but can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

Which collection of risk factors will most likely result in damaging lacerations, including episiotomies? a. Dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. Reddish-haired mother of two who is going through a breech birth c. Dark-skinned first-time mother who is going through a long labor d. First-time mother with reddish hair whose rapid labor was overseen by an obstetrician

ANS: D Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient. The rate of episiotomies is higher when obstetricians rather than midwives attend the births. The woman in the first scenario (a) is at low risk for either damaging lacerations or an episiotomy. She is multiparous, has dark skin, and is being attended by a midwife, who is less likely to perform an episiotomy. Reddish-haired women have tissue that is less distensible than that of darker-skinned women. Consequently, the client in the second scenario (b) is at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy. The fact that the woman in the third scenario (c) is experiencing a prolonged labor might increase her risk for lacerations. Fortunately, she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury.

A new mother asks the nurse when the "soft spot" on her son's head will go away. What is the nurse's best response, based upon her understanding of when the anterior frontal closes? a. 2 months b. 8 months c. 12 months d. 18 months

ANS: D The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. The remaining three options are too early for the anterior fontanel to close.

The nurse performs a vaginal examination to assess a client's labor progress. Which action should the nurse take next? a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.

ANS: D The nurse should discuss the findings of the vaginal examination with the woman and her partner, as well as report the findings to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned so as to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse's highest priority in this situation? a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate (FHR) and pattern.

ANS: D The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the ROM to ascertain fetal well-being, and the findings should be documented. The ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary health care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The FHR has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. What disposition would the nurse anticipate? a. Admitted and prepared for a cesarean birth b. Admitted for extended observation c. Discharged home with a sedative d. Discharged home to await the onset of true labor

ANS: D This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. No further assessments or observations are indicated; therefore, the client will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time.

Maternity nurses often have to answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief isaccurate? a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than one long bath. Counterpressure can help the woman cope with lower back pain.

A pregnant woman is at 38 weeks of gestation. She wants to know whether there are any signs that "labor is getting close to starting." Which finding is an indication that labor may begin soon? a. Weight gain of 1.5 to 2 kg (3 to 4 lb) b. Increase in fundal height c. Urinary retention d. Surge of energy

ANS: D Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, as a result of water loss caused by electrolyte shifts that, in turn, are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor.

The nurse is caring for a pregnant client whose cervix has dilated to 5 cm and the membranes have ruptured. What assessments does the nurse perform to prevent complications during childbirth? Body temperature every 2 hours Fetal heart rate and activity every hour Blood pressure and pulse every 30 minutes Presence of vaginal show every 15 minutes Change in the maternal mood and energy levels every 5 minutes

Body temperature every 2 hours Blood pressure and pulse every 30 minutes Presence of vaginal show every 15 minutes Rationale Cervical dilatation of 5 cm along with ruptured membranes indicates that the client is in the active phase of the first stage of labor. Because the membranes have ruptured, the nurse should assess the client's body temperature every 2 hours, because elevated body temperature may indicate sepsis. Vital parameters such as blood pressure, heart rate, and respiratory rate should be recorded every 30 minutes. Changes in these parameters could indicate cardiopulmonary instability. The nurse should assess for vaginal show every 15 minutes to determine the progress of labor. Fetal heart rate and activity should be assessed every 30 minutes for a client who is in her active phase of first stage of labor. The nurse should monitor the client's mood and energy levels every 15 minutes while the client is in the active phase of first stage of labor.

Pain impulses during the second stage of labor

Pain impulses during the second stage of labor are transmitted via the pudental nerve through S2 to S4 spinal nerve segments and the parasympathetic system.

Duration

The time that passes between the onset and the end of a contraction

music

can provide a distraction, enhance relaxation, and lift spirts during labor, thereby reducing the woman's level of stress, anxiety, and perception of pain

fourth stage of labor

delivery of placenta and 2 hr after birth

marked variability

fetal heart rate fluctuations are greater than 25 beats min

position

relationship of a reference point on the presenting part (occiput, sacrum, mentum (chin), or sinciput (deflexed vertex) to the four quadrants of the mother's pelvis 3 part abbreviation

pudendal nerve block

relief from pain in the lower vagina, vulva, and perineum, making it useful if an episiotomy is to be performed or forceps or vacuum-assistance is required to facilitate birth

epidural analgesia/anesthesia (block)

relief from pain of uterine contractions and birth by injecting a local anesthetic agent and/or opioid agonist analgesic into the peridural space

regional analgesia

some pain relief and motor block

Cesearean birth meds

spinal block anesthesia epidural block anesthsia general anesthesia

during early labor

stay home warm shower massage diversinal activities

counter pressure

steady pressure applied against the laboring woman's sacrum by the nurse or coach using the fist or heel of the hand or a firm object; it is especially helpful during back labor

intensity of contractions

strength of contraction at its peak

episiotomy

surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth

pelvic joints

symphysis oubis right and left sacroiliac joints sacrococcygeal joint

..opioid agonist analgesic.

systemic analgesic such as meperidine or fentanyl that relieves pain and creates a feeling of well-being, but can result in respiratory depression, nausea, and vomiting

Which physiological forces play the most significant role in complete dilatation of the cervix? Pain Dilatation Effacement Contractions

Contractions Each contraction works to facilitate complete dilatation and effacement throughout all stages of labor.

opiod agonist-antagonist analgesia

systemic analgesic such as nalbuphine and butorphanol that relieves pain without causing significant maternal or neonatal respiratory depression and less likely to cause nausea and vomiting

therapeutic touch

technique that uses the concept of energy fields within the body called prana that are thought to be deficient in some people who are in pain. it involves the laying-on-of hands by a specially trained person to redirect energy fields associated with pain

causes variable decelerations

umbilical cord compression caused by the following 1. maternal osition with cord between fetus and maternal pelvis 2. cord around fetal neck, arm, leg, or other body parts 3. short cord 4. knot in cord 5. prolapsed cord

Forceps delivery

1. Two double-crossed, spoon-like articulated blades are used to assist in the delivery of the fetal head. 2. Reassure the mother and explain the need this type of delivery. 3. Monitor the mother and fetus during delivery. 4. Check neonate and mother after delivery for any possible injury. 5. Assist with repair of any lacerations.

The Bishop score

1. Used to determine maternal readiness for labor and evaluates cervical status and fetal position. 2. Is indicated before the induction of labor. 3. The five factors are assigned a score of 0 to 3, and the total score is calculated. 4. A score of 6 or more indicates a readiness for labor induction.

Basic Corrective Measures if FHR is abnormal

-providing supplemental oxygen (10L/min for approximately 15-30 minutes) -instituting maternal position changes (move patient to side-lying position -increasing intravenous fluid administration GOAL OF THESE INTERVENTIONS: --Improve uterine and intervillous space blood flow -increase maternal oxygenation and cardiac output

Interventions for Uterine Tachysystole

-reduce or discontinue the dose of any uterine stimulants (e.g. oxytocin, Pitocin) -Administer a uterine relaxant (e.g. brethine)

expression of pain

-sympathetic nervous system is stimulated ( increased catecholamine) -BP and HR increases - increased oxygen consumption ( and RR) hyperventilation, respiratory alkalosis pallor, diaphresis increased gastric acidity nausea, vomiting placental perfusion decreased, uterine activity may diminish increased anxiety, crying, groaning, gesturing

Ultrasound Transducer

-used in external fetal monitoring to measure FHR and uterine contractions -uses soundwaves to detect fetal heart rate

Latent phase of labor:

0-3 cm Contractions are irregular, mild to moderate Frequency is 5-30 mins Duration is 30-45 secs Client talkative and excited

latent

0-3 cm dilation occurs during the latent (early) phase (Lasts about 6-8 hours) Contractions during the __ stage of the first stage of labor are... Mild to moderate Irregular 5-30 min apart 30-45 seconds

The nurse is providing care for a client in labor. What does the nurse instruct the client in the second stage of labor? "Point your toes, to prevent pain." "Avoid fluids until the infant is delivered." "Lie still and avoid movement to prevent fatigue." "Avoid holding your breath or tightening the abdominal muscles."

"Avoid holding your breath or tightening the abdominal muscles." Rationale The client may hold her breath and tighten the abdominal muscles for pushing during the second stage of labor. This activity is known as the Valsalva maneuver. The activity increases intrathoracic pressure, reducing venous return while increasing venous pressure. Therefore, the nurse instructs the client to avoid the Valsalva maneuver. The client should not point her toes, because it may cause leg cramps. The client should not avoid fluids if thirsty, because it may cause dehydration. The nurse should instruct the client to change positions every few minutes in order to facilitate delivery during the second stage of labor.

A woman at 39 weeks' gestation reports concern regarding vaginal secretions that are a mixture of blood and mucus. The nurse explains that this occurs for which reason? "Bloody show" occurs as a result of cervical changes during false labor. "Bloody show" occurs as the cervix begins to soften, dilate, and efface slightly. "Bloody show" occurs as fetal pressure causes congestion of the vaginal mucosa. "Bloody show" occurs because extra amniotic fluid that accumulates during pregnancy is being excreted.

"Bloody show" occurs as the cervix begins to soften, dilate, and efface slightly. "Bloody show," a mixture of thick mucus and pink or dark brown blood, may occur as the cervix begins to soften, dilate, and efface slightly ("ripening").

The nurse is assisting a pregnant client in labor. What instructions should the nurse give to the client to promote comfort? Select all that apply. "You should cough frequently." "Breathe with your mouth open." "Lie down in the lateral position." "Lie in the supine position in bed." "Lie in the semi-Fowler's position."

"Breathe with your mouth open." "Lie down in the lateral position." "Lie in the semi-Fowler's position." Rationale The nurse helps the pregnant client during labor. This includes teaching the client relaxation techniques. The nurse teaches the client to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the client in a semi-Fowler's or lateral position is helpful during labor. Therefore the nurse should instruct the client to maintain the lateral or semi-Fowler's position with a lateral tilt. Asking the client to cough frequently would increase the intraabdominal pressure of the client and would make the client uncomfortable. Having the client lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the client to lie down in a position other than supine.

How would the nurse best respond to a laboring patient who is concerned that not enough monitoring is being performed? "This is just the way it is done." "Can you tell me why you feel this way?" "If your partner can leave the room, we can discuss this further." "I do not have the authority to explain this. I will call your primary health care provider."

"Can you tell me why you feel this way?" The nurse needs to validate the patient's feelings and find out why she feels that way. Then explain the reasoning for the level of monitoring.

A client who is at 30 weeks gestation reports a brownish cervical discharge. What questions does the nurse ask first in order to identify the cause of the discharge? "Are you experiencing abdominal pain?" "Are you experiencing strong uterine contractions?" "Did you have sexual intercourse in the last two days?" "Did you take any other medications than those prescribed?"

"Did you have sexual intercourse in the last two days?" Rationale Sexual intercourse during this period of the pregnancy may cause cervical trauma and result in cervical discharge. Therefore, the nurse should first ask whether the client had intercourse in the last two days. Abdominal pain and strong uterine contractions are indicative of labor, but the client is unlikely to go into labor at this time. Medications should not generally cause production of brownish cervical discharge, so this is not a priority question at this time.

A postpartum client is worried because her newborn's head has an abnormal shape instead of being round. The delivery documentation indicates that the newborn had molding upon delivery. What is nurse's best response? "The infant will look better after more hair grows." "The infant's skull needs to be massaged after a month." "The infant's head will assume a normal shape in 3 days." "Some infants have an oddly shaped head, which is alright."

"The infant's head will assume a normal shape in 3 days." Rationale The fetal skull bones are not completely fused and there may be a slight overlapping of the bones during the labor process. This causes molding of the fetal head. The molding is not permanent and the infant's head assumes a normal shape within 3 days of birth. Telling the client that the infant will look better after hair growth will not help alleviate the client's anxiety about the fetal head. The infant's head will assume a normal shape within 3 days, and the client need not wait for a month to massage the infant's head. Some infants may have an oddly shaped head, but in this case, the molding has occurred due to the labor.

A client complains of the urge to have a bowel movement during each contraction. What does the nurse inform the client ? "There is a possibility of an infection." "I will have to evaluate your urine reports." "There is a complication with the delivery." "This is a normal occurrence at the onset of labor."

"This is a normal occurrence at the onset of labor." Rationale Frequent bowel movements may be seen in some clients at the onset of labor because of the presence of stool in the rectum. Therefore, the nurse should instruct the client that it is a normal occurrence. Bowel movement during each contraction does not indicate an infection, so there is no need to evaluate the urine reports. The possibility of a complication during delivery can be confirmed only after evaluating the ultrasound reports of the client.

The nurse is teaching a group of nursing students about fetal oxygenation. The nurse questions a student, "What happens when oxytocin levels are elevated in the client?" What would be the most appropriate answer given by the nursing student related to the client's condition? "Hemoglobin levels will decrease." "Blood glucose levels will increase." "Placenta lowers the blood supply." "Uterine contractions (UCs) will increase."

"Uterine contractions (UCs) will increase." Rationale An elevated level of oxytocin increases UCs during labor. Reduced hemoglobin levels lead to a decreased oxygen supply to the fetus, but are not a complication associated with an elevated oxytocin level. Oxytocin has no effect on blood glucose levels. A family history of diabetes may increase the risk of gestational diabetes in the client. Conditions such as hypertension in the client may lower the blood supply to the placenta, but are not associated with oxytocin levels.

A woman is concerned about the baseline variability in the fetal heart rate of her fetus. Which response by the nurse describes the significance of baseline variability to the woman? Select all that apply. "Variability is an artifact." "Variability is a periodic pattern." "Variability demonstrates that there is adequate oxygenation of the fetus." "Variability suggests that the fetus is able to adapt to the labor process." "Variability indicates that the fetus has no congenital abnormalities."

"Variability demonstrates that there is adequate oxygenation of the fetus." Adequate oxygenation of the fetus, demonstrated by variability, is necessary and therefore variability is significant. Correct "Variability suggests that the fetus is able to adapt to the labor process." Variability is significant because its presence indicates that the autonomic nervous system is intact, allowing the fetus to adapt to the normal stress of labor.

physiological factors affecting pain response

-fatigue -the interval and duration of contractions -fetal size and position -rapidity of fetal descent -maternal position - maternal mobility during labor when beta endorphin level increases, pain threshhold may increase as well

Tocotransducer

-measures uterine contractions and tone transabdominally -device is placed over the fundus and held securely in place by an elastic belt -used in external fetal monitoring

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1 Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery.

A woman has just arrived at the labor and delivery suite. In order to report the client's status to her primary health care practitioner, which of the following assess ments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Contraction stress test. 4. Vital signs. 5. Biophysical profile.

1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the health care provider. 2. The nurse should assess the contrac tion pattern before reporting the client's status. 3. A contraction stress test is only performed if ordered by a health care practitioner. 4. The nurse should assess the woman's vital signs before reporting her status. 5. A biophysical profile is only performed if ordered by a health care practitioner.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3

2 A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2 The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time.

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

2 The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client's primary support person(s) is not the priority action at this time.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus is in full term 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

2. The fetal head has entered the true pelvis.

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? 1. Spontaneous fetal movement. 2. Fetal heart acceleration. 3. Increase in fetal heart variability. 4. Resolution of late decelerations.

2. The fetal heart should accelerate in response to scalp stimulation.

A low-risk 38-week-gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucus plug." 4. "How much blood is there?"

2. The nurse is using reflection to ac knowledge the client's concerns.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when re porting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor. There is no need for her to be hospitalized at this time.

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. The woman should be encouraged to grunt during contractions.

A client is in the second stage of labor. She falls asleep immediately after a contrac tion. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. The woman's privacy should be main tained while she is resting.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than Icould then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

3. This response indicates that the labor contractions are increasing in intensity.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests. 2. Focusing the discussion on baby care rather than labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

3. Using visual aids can help to foster learning in teens as well as adults.

It is 4 p.m. A client, G1P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4. This is the best response. 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

Which laboring client does the nurse expect to be a likely candidate for amnioinfusion? A client with heavily meconium-stained amniotic fluid (or a low amniotic fluid index [AFI]) A client with an increase in uterine activity A client with hypertension and diabetes A client with an overdistended uterine cavity

A client with heavily meconium-stained amniotic fluid (or a low amniotic fluid index [AFI]) Rationale Amnioinfusion is the infusion of room-temperature isotonic fluid into the uterine cavity when the volume of amniotic fluid is low. Clients with premature rupture of membranes are likely to receive an amnioinfusion. The nurse should discontinue the administration of oxytocin for a client with increased uterine activity. Hypertension and diabetes are not factors that indicate the need for amnioinfusion. Pregnant clients with hypertension need to have their blood pressure monitored. Pregnant clients with diabetes need to have their blood glucose levels monitored. Clients receiving amnioinfusion are at a risk for overdistention of the uterine cavity,because amnioinfusion increases the amniotic fluid volume.

Which signs precede the onset of labor? Select all that apply. A return of urinary frequency, because of increased bladder pressure Persistent low backache, from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions A decline in energy, as the body stores up for labor Weight loss of 0.5 to 1.5 kg

A return of urinary frequency, because of increased bladder pressure Persistent low backache, from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions Weight loss of 0.5 to 1.5 kg Rationale After lightening, a return of the frequent need to urinate occurs, because the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Prior to the onset of labor it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed and weight loss of 0.5 to 1.5 kg will occur. A surge of energy is a phenomenon that is common in the days preceding labor.

Which statement is accurate with regard to normal labor? Select all that apply. A single fetus presents by vertex. It is completed within 8 hours. A regular progression of contractions, effacement, dilation, and descent occurs. No complications are involved. Mechanisms of labor are involved.

A single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent occurs. No complications are involved. Mechanisms of labor are involved. Rationale In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor. A normal labor usually has no complications and the movements of the mechanisms of labor are present. Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours.

Which premonitory labor sign becomes apparent when changing levels of estrogen and progesterone cause excretion of some of the extra interstitial fluid that accumulates in body tissue during pregnancy? "Bloody show" Braxton Hicks contractions A small weight loss of 1 to 3 lb (2.2 kg to 6.6 kg) Increased clear and nonirritating vaginal secretions

A small weight loss of 1 to 3 lb (2.2 kg to 6.6 kg) A small weight loss of 1 to 3 lb (2.2 kg to 6.6 kg) may occur because changing levels of estrogen and progesterone cause excretion of some of the extra interstitial fluid that accumulates during pregnancy.

Fetal Heart Rate Acceleration

A visually apparent abrupt increase in FHR above the baseline rate (onset to peak less than 30 seconds) -normal- indicate normal fetal acid-base balance; no nursing interventions required -peak must be at least 15 bpm above the baseline and the acceleration must last 15 seconds or more and return to baseline less than 2 minutes from the beginning of the acceleration (before 32 weeks of gestation, defined as a peak of 10 bpm or more above the baseline and a duration of at least 10 seconds, must return to baseline within 10 minutes)

An anesthesiologist is preparing to begin a continuous epidural block using a combination local anesthetic and opioid analgesic as a pain relief measure for a laboring women. Nursing measures related to this type of nerve block include: (Circle all that apply.) A) Assist the women into a modified Sims position or upright position with back curved for administration of the block. B) Alternate her position from side to side every hour. C) Assess the women for headaches, because they commonly occur in the postpartum period if an epidural is used for labor. D) Assist the women to urinate at least every 2 hours during labor to prevent bladder distension. E) Prepare the women for use of forceps- or vacuum-assisted birth, because she will unable to bear down. F) Assess blood pressure frequently, because severe hypotension can occur.

A) Assist the women into a modified Sims position or upright position with back curved for administration of the block. B) Alternate her position from side to side every hour. E) Prepare the women for use of forceps- or vacuum-assisted birth, because she will unable to bear down. F) Assess blood pressure frequently, because severe hypotension can occur.

The nurse should be cognizant of which important information regarding nerve block analgesia and anesthesia? a. Most local agents are chemically related to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. Pudendal nerve block is designed to relieve the pain from uterine contractions. d. Pudendal nerve block, if performed correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions. A pudendal nerve block lessens or shuts down the bearing-down reflex.

Which client would not be a suitable candidate for internal EFM? a. Client who still has intact membranes b. Woman whose fetus is well engaged in the pelvis c. Pregnant woman who has a comorbidity of obesity d. Client whose cervix is dilated to 4 to 5 cm

ANS: A For internal EFM, the membranes must have ruptured and the cervix must be dilated at least 2 to 3 cm. The presenting part must be low enough to allow placement of the spiral electrode necessary for internal EFM. The accuracy of EFM is not affected by maternal size. However, evaluating fetal well-being using external EFM may be more difficult on an obese client. The client whose cervix is dilated to 4 to 5 cm is indeed a candidate for internal monitoring.

In recovery, if a woman is asked to either raise her legs (knees extended) off the bed or flex her knees, and then place her feet flat on the bed and raise her buttocks well off the bed, the purpose of this exercise is to assess what? a. Recovery from epidural or spinal anesthesia b. Hidden bleeding underneath her c. Flexibility d. Whether the woman is a candidate to go home after 6 hours

ANS: A If the numb or prickly sensations are gone from her legs after these movements, then she has likely recovered from the epidural or spinal anesthesia. Assessing the client for bleeding beneath her buttocks before discharge from the recovery is always important; however, she should be rolled to her side for this assessment. The nurse is not required to assess the woman for flexibility. This assessment is performed to evaluate whether the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

Which alterations in the perception of pain by a laboring client should the nurse understand? a. Sensory pain for nulliparous women is often greater than for multiparous women during early labor. b. Affective pain for nulliparous women is usually less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Breathing patterns are taught to laboring women. Which breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes? a. Slow-paced breathing b. Deep abdominal breathing c. Modified-paced breathing d. Patterned-paced breathing

ANS: A Slow-paced breathing is approximately one half the woman's normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions. No such pattern called deep abdominal breathing exists in childbirth preparation. Modified-paced breathing is shallow breathing that is twice the woman's normal breathing rate. It is used when labor progresses and the woman can no longer maintain relaxation through paced breathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.

What is the nurse's understanding of the appropriate role of primary and secondary powers? a. Primary powers are responsible for the effacement and dilation of the cervix. b. Effacement is generally well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies. c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

ANS: A The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement is generally well ahead of dilation in first-time pregnancies; they are closer together in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a. Nonreassuring or abnormal FHR pattern b. Inadequate uterine relaxation c. Vaginal bleeding d. Prolonged second stage e. Prolapse of the cord

ANS: A, B, C, E A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention. A prolonged second stage of labor after the upper limits for duration is reached. This is 3 hours for nulliparous women and 2 hours for multiparous women.

Which alternative approaches to relaxation have proven successful when working with the client in labor? (Select all that apply.) a. Aromatherapy b. Massage c. Hypnosis d. Cesarean birth e. Biofeedback

ANS: A, B, C, E Approaches to relaxation can include neuromuscular relaxation, aromatherapy, music, massage, imagery, hypnosis, or touch relaxation. Cesarean birth is a method of delivery, not a method of relaxation.

Which statement concerning the third stage of labor is correct? a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

ANS: B Active management facilitates placental separation and expulsion, reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhaging.

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity? a. To facilitate maternal-newborn interaction b. To stimulate the uterus to contract c. To prevent neonatal hypoglycemia d. To initiate the lactation cycle

ANS: B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhaging. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth.

Which statement related to fetal positioning during labor is correct and important for the nurse to understand? a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor.

ANS: B The station of the presenting part should be noted at the beginning of labor to determine the rate of descent. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother's pelvis; station is the measure of degree of descent. The largest diameter is usually the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparous women and before or during labor in multiparous women.

Which are progressive changes that occur to the cervix during labor? Select all that apply. Rupture Prolapse Dilatation Laceration Effacement

Dilatation Dilatation (opening) of the cervix occurs when the cervix is pulled downward and the fetus is pushed upward. Effacement Effacement (thinning and shortening) of the cervix occurs when the cervix becomes shorter and thinner as it is drawn over the fetus and amniotic sac.

The nurse has received a report regarding a client in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and -2. What is the nurse's interpretation of this assessment? a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines. b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines. d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

ANS: B The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.

The first 1 to 2 hours after birth is sometimes referred to as what? a. Bonding period b. Third stage of labor c. Fourth stage of labor d. Early postpartum period

ANS: C The first 2 hours of the birth are a critical time for the mother and her baby and is often called the fourth stage of labor. Maternal organs undergo their initial readjustment to a nonpregnant state. The third stage of labor lasts from the birth of the baby to the expulsion of the placenta. Bonding will occur over a much longer period, although it may be initiated during the fourth stage of labor.

21. A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is approximately twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. Which intervention should the nurse immediately initiate? a. Contact the woman's physician. b. Tell the woman to slow her pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag.

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis and enable her to rebreathe carbon dioxide and replace the bicarbonate ion.

A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural "no matter what!" What is the nurse's best response? a. "I'll make sure you get your epidural." b. "You may only have an epidural if your physician allows it." c. "You may only have an epidural if you are going to deliver vaginally." d. "The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth."

ANS: D To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm. A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained. A physician's order is required for pharmacologic options for pain management. However, expressing this requirement is not the nurse's best response. An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Lull: no contractions; dilation stable; duration of 20 to 60 minutes Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours Full cervical dilation marks the end of the first stage of labor

Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Full cervical dilation marks the end of the first stage of labor Rationale The active stage is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes. Full cervical dilation marks the end of the first stage of labor. No official "lull" phase exists in the first stage. Text Reference: pp. 374, 376

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Lull: no contractions; dilation stable; duration of 20 to 60 minutes Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. Which actions should the nurse anticipate in the woman's plan of care? Select all that apply. Keeping the head of bed elevated at all times Administering oral analgesics Avoiding caffeine Assisting with a blood patch procedure Frequently monitoring vital signs

Administering oral analgesics Assisting with a blood patch procedure Frequently monitoring vital signs Rationale Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential. The nurse should suspect the client is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief.

After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. Which actions should the nurse anticipate in the woman's plan of care? Select all that apply. Keeping the head of bed elevated at all times Administering oral analgesics Avoiding caffeine Assisting with a blood patch procedure Frequently monitoring vital signs

Administering oral analgesics Assisting with a blood patch procedure Frequently monitoring vital signs Rationale Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential. The nurse should suspect the client is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief.

The nurse is caring for a multiparous client. In which stage can the nurse expect the fetal head to be engaged in the pelvic inlet? About 2 weeks before term Before the start of active labor When labor stage I begins After labor is established

After labor is established Rationale In a multiparous client, the abdominal musculature is relaxed. The fetal head often remains freely movable above the pelvic brim, and becomes engaged in the pelvic inlet only after labor is established. In a nulliparous client, the uterus sinks downward and forward about 2 weeks before term, when the presenting part of the fetus descends into the true pelvis. The fetal head is engaged in the pelvic inlet before the onset of active labor. The abdominal muscles are firm in a nulliparous pregnancy and direct the presenting part into the pelvis. The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix.

A nurse is assessing a fetal heart rate and notes absent baseline activity that does not resolve on altering the position of the mother or administration of oxygen. Which is the most appropriate nursing action? Administer a tocolytic. Alert the primary health care provider. Begin continuous electronic fetal monitoring. Educate the woman on potential causes and solutions.

Alert the primary health care provider. A nonreassuring, severe pattern, such as absent baseline activity, and does not resolve with supportive measures, necessitates the attention of the primary health care provider. Other staff should be notified of a possible immediate delivery and neonatal resuscitation.

The nurse is using auscultation to determine the fetal heart rate (FHR) during the first stage of labor. What measures can the nurse use to reassure the mother if it takes considerable time to locate and count the heartbeats? Ask the health care provider to locate the heartbeat. Let the mother know the sounds are muffled. Use internal monitoring to locate the heartbeat. Allow the mother to listen to the heartbeat.

Allow the mother to listen to the heartbeat. Rationale The client may become anxious if the nurse takes considerable time to locate and count the fetal heartbeats. The nurse can reassure the mother by allowing the mother to listen to the heartbeat after it is located. The nurse may seek assistance if necessary to identify the fetal heartbeat; however, the nurse is usually capable of locating the heartbeat with patience, and escalating the intervention to a health care provider can sometimes increase anxiety in the client. The nurse must let the mother know that it takes time to identify the spot with the loudest and clearest heartbeats that can be counted. The nurse need not tell the mother that the sounds are muffled. The nurse must use an ultrasound to locate the heartbeat during the first stage of labor. Internal monitoring is possible only when the cervix is dilated sufficiently and the membranes are ruptured.

A nurse is educating a patient about the difference between low-tech and high-tech fetal surveillance. How would the nurse describe the advantages of low-tech fetal surveillance methods, such as intermittent auscultation? Select all that apply. Allows patient movement Allows for a less medical atmosphere Appropriate for low-risk pregnant patients in labor Offers patient more freedom in choosing pain management Allows the nurse to assess the FHR during every contraction

Allows patient movement Intermittent auscultation of the FHR allows more mobility than high-tech methods. Allows for a less medical atmosphere Intermittent auscultation is intermittent, and the patient is not focused on watching the monitor and listening to beeping noises. Appropriate for low-risk pregnant patients in labor Intermittent auscultation is not the preferred method if the pregnancy is complicated or high risk. Continuous external or internal electronic fetal monitoring is preferred with high-risk pregnancies. Offers patient more freedom in choosing pain management Intermittent auscultation does allow the patient to use water-based methods, that is, whirlpool for pain management, because no equipment is attached continuously.

The nurse is briefing a client who is pregnant for the first time about "lightening." Which statement should the nurse mention to describe lightening to the client? Occurs when true labor is in progress. Allows the client to breathe more easily. Decreases the pressure on the bladder. Leads to decreased urinary frequency.

Allows the client to breathe more easily. Rationale When the fetal head descends into the true pelvis during "lightening," the client will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency.

culture affect on pain response

Although all women expect to experience at least some pain and discomfort during childbirth, it is their cultural and religious belief system that determine how well they will perceive, interpret, respond to, and manage their pain. Cultural influences may impose certain behavioral expectations regarding acceptable and unacceptable behavior when experiencing pain.

The nurse is assisting a client in labor. What neurologic changes does the nurse expect in the laboring client? Decreased pain threshold. Amnesia and sedation. Increased perception of pain. Client is elated between contractions.

Amnesia and sedation. Rationale The client experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the client may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth.

The nurse is performing the pelvic examination of a client during the prenatal visit. Which pelvic type is heart shaped and least favorable for a vaginal birth? Gynecoid Android Anthropoid Platypelloid

Android Rationale The android pelvis is heart shaped and angulated. The sidewalls are convergent; the sacrum is slightly curved and the terminal portion is often beaked. The subpubic arch is narrow, often resulting in cesarean births or difficult vaginal forceps birth. It is least favorable for vaginal birth. The gynecoid pelvis is slightly ovoid or transversely rounded. The side walls are straight, sacrum deep and curved. The subpubic arch is wide, thus enabling spontaneous vaginal births. The anthropoid pelvis is oval and wider anteroposteriorly. The sidewalls are straight, sacrum slightly curved. The subpubic arch is narrow and may result in forceps vaginal birth. The platypelloid pelvis is flattened anteroposteriorly and wide transversely. The side walls are straight, the sacrum slightly curved, and the subpubic arch is wide, resulting in spontaneous vaginal birth.

Which assessment finding in the client increases the risk for a forceps assisted birth? Android pelvis Effacement of the cervix Biparietal diameter of 9.25 cm Involuntary uterine contractions (UCs)

Android pelvis Rationale An android pelvis has a narrow subpubic arch and the ischial spines have a narrow interspinous diameter. As a result, the client will have difficulty during a vaginal birth and may require a forceps-assisted delivery. Effacement of the cervix takes place at the onset of the labor and indicates that the client is in labor. A biparietal diameter of 9.25 cm indicates normal fetal head growth, which can be delivered vaginally. Involuntary UCs indicate that the client is in labor.

The nurse observes late decelerations in the fetal heart rate (FHR) while caring for a client in labor. Which nursing intervention does the nurse perform for this client? Arrange for internal fetal heart rate monitoring. Increase the dosage of exogenous oxytocin. Provide external sound stimulation. Assist the client to knee chest position.

Arrange for internal fetal heart rate monitoring. Rationale If the nurse notices late FHR decelerations, then the nurse must arrange for internal monitoring to obtain a more accurate fetal and uterine assessment. The nurse may need to help prepare for cesarean birth if the pattern cannot be corrected. The nurse must discontinue any infusion of oxytocin, because it may cause uterine hypertonus, leading to reduction in blood flow to the intervillous space in the placenta, causing fetal hypoxia. The nurse only provides external sound stimulation in order to elicit FHR accelerations during an NST test. The client must be assisted to a lateral position, not a knee-to-chest position. The knee-to-chest position is used if the nurse suspects umbilical cord compression.

Amniotomy

Artificial rupture of the membranes is performed by the health care provider (HCP) or nurse-midwife to stimulate labor. 1. Artificial rupture of the membranes is performed by the health care provider (HCP) or nurse-midwife to stimulate labor. 2. Performed if the fetus is at 0 or a plus station. 3. Increases the risk of prolapsed cord and infection. 4. Monitor FHR before and after. 5. Record time of procedure, FHR, and characteristics of the fluid. 6. Meconium-stained amniotic fluid may be associated with fetal distress. 7. Bloody amniotic fluid may indicate abruptio placentae or fetal trauma. 8. An unpleasant odor to amniotic fluid is associated with infection. 9. Polyhydramnios is associated with maternal diabetes and certain congenital disorders. 10. Oligohydramnios is associated with intrauterine growth restriction and congenital disorders. 11. Expect more variable decelerations after rupture of the membranes as a result of possible cord compression during contractions. 12. Limit client activity if prescribed.

The nurse is preparing a patient for hydrotherapy to promote relaxation during labor. The pregnancy reports of the client indicate that the fetus is in a occiput posterior position. What is a priority action in this case? Instruct the client to assume an upright position. Ask the client to assume a side-lying position in the tub. Obtain an order for pharmacologic pain relief measures. Instruct the client to avoid changing positions in the water.

Ask the client to assume a side-lying position in the tub. Rationale The nurse instructs the client to assume a side-lying position in the tub, because it increases buoyancy and enhances spontaneous fetal rotation to the occiput anterior position. An upright position is not helpful in this case, because it will not relieve the "back labor" that may occur due to the transverse position of the fetus. Pharmacologic pain relief measures are not necessary in this case, because a change in position is effective in relieving pain.

A laboring gravida 2, para 1 is being cared for on the family birth unit. Her cervix is currently 5 cm dilated and 100% effaced. The fetus is at -2 station and cephalic in a left occiput anterior position. The patient calls the nurse to the room and reports a large gush of fluid with her most recent contraction. The nurse assesses that the patient's membranes are ruptured and that the amniotic fluid is green and watery. What is the most important nursing intervention at this time? Call the practitioner and report ruptured membranes with no abnormal findings. Reposition the patient onto her back for comfort. Assess FHR to check for any change in baseline or any abnormal patterns. Assist the patient to the bathroom to shower.

Assess FHR to check for any change in baseline or any abnormal patterns.

The nurse is caring for a client who is in labor. Which interventions would promote safety when assisting the patient with showering? Select all that apply. Assess for progress in labor. Pour warm water over the client's vulva. Place the client's hand in warm water. Supervise showers during true labor. Help the client in oral hygiene

Assess for progress in labor. Supervise showers during true labor. Rationale A warm shower may help relieve discomfort in pregnant client who are in labor. Before the client showers, the nurse should first assess her progress in labor to determine if the client is close to delivery. The nurse should supervise the client during the shower to prevent a fall. Pouring warm water over the client's vulva and placing her hand in warm water during a shower may not promote safety. These interventions may help the client to urinate. Assisting the client in oral hygiene may promote oral health, but may not be helpful in promoting safety.

In which ways can a nurse evaluate the recovery of a patient who gave birth vaginally? Select all that apply. Assess respirations every 15 minutes. Assess the quality and quantity of the lochia. Assess the position and consistency of the uterus. Assess the intactness and characteristics of the perineum. Assess the patient's breasts and nipples before the initial breastfeeding event.

Assess respirations every 15 minutes. The nurse should assess respirations every 15 minutes following the first hour of delivery. Assess the quality and quantity of the lochia. Assessing the amount and quality of the lochia provides information regarding the presence of retained placenta fragments and potential post-partum hemorrhage. Assess the position and consistency of the uterus. Assessing the position and consistency of the uterus in the first hour after delivery allows the nurse to monitor for signs of post-partum hemorrhage. Assess the intactness and characteristics of the perineum. The nurse must be on alert for increasing edema, ecchymosis, or hematomas in the perineum, all of which could cause serious complications for the patient.

Which intervention would the nurse use to decrease the patient's anxiety or fear about electronic fetal monitoring? Instruct the patient to stay away from water with the monitor on. Instruct the patient not to move during the electronic fetal monitoring. Assess the parents' present knowledge about electronic fetal monitoring. Inform the patient that volume must be loud enough to hear from the hallway or nursing station

Assess the parents' present knowledge about electronic fetal monitoring. To decrease a patient's anxiety about electronic fetal monitoring, the nurse should first assess the parents' present knowledge about electronic fetal monitoring, while building on existing knowledge.

While assessing a pregnant client using a fetoscope, the nurse also palpates the abdomen of the client. What is the purpose of palpating the abdomen of the client? Detection of fetal heart rate deceleration Evaluation of the severity of the pain caused by active labor Assessment of pain from pressure applied by the fetoscope Assessment of changes in fetal heart rate during and after contraction

Assessment of changes in fetal heart rate during and after contraction

hypertonic uterine activity

Assessment of uterine activity includes frequency, duration, intensity of contractions, and uterine resting tone. The uterus should relax between contractions for 60 seconds or longer. Uterine contraction intensity is about 50 to 75 mm Hg during labor and may reach 110 mm Hg with pushing during the second stage. The average resting tone is 5 to 15 mm Hg. In hypertonic uterine activity, the uterine resting tone between contractions is high, reducing uterine blood flow and decreasing fetal oxygen supply.

The nurse is reviewing the physical assessment data of a client in the fourth stage of labor. Which immediate intervention does the nurse provide after reviewing the data? Massage the abdomen and clean the perineum using warm water. Assist the client to void spontaneously. Clean the vaginal lacerations with tap water. Assist the client to flex her hip, and wash the perineum using hot water.

Assist the client to void spontaneously. Rationale A palpable and distended bladder may indicate urinary retention. A distended bladder may lead to fundal atony, increasing the risk of postpartum hemorrhage and bleeding. Perineal pain and drainage is common during postpartum period. The nurse should encourage the client to void spontaneously to help the bladder return to its nonpalpable stage. It also helps to increase the tone of the uterine fundus and makes it firm. Massaging the abdomen helps the uterus to contract. Cleaning the perineum using warm water reduces the client's discomfort and relieves perineal pain. Cleaning vaginal lacerations is not an appropriate intervention, because there are no lacerations reported in this client's data. A nurse assists a client to flex her upper leg on the hip to observe vaginal lacerations, and using warm water is preferred to hot water.

The nurse teaches the client nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. Biofeedback Massage and touch Patterned breathing Controlled relaxation Slow-paced breathing

Biofeedback Patterned breathing Controlled relaxation Rationale Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the client is able to focus and control body responses during labor. The nurse assisting the laboring client can use methods such as massage and touch and slow-paced breathing successfully without the client having any prior knowledge about it.

Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetrical client who is in early labor? Biparietal diameter of less than 9.25 cm Vertex presenting part Transverse lie General flexion attitude Android pelvis

Biparietal diameter of less than 9.25 cm Transverse lie Android pelvis Rationale A biparietal diameter at term is typically noted at 9.25 cm and a finding that this measurement is less than that would cause concern related to the mode of delivery. A transverse lie would cause a concern relative to the mode of delivery, because a C section would be indicated. An android pelvis would cause a concern related to the mode of delivery. A vertex presenting part is a normal finding and would not cause concern. A general flexion attitude is a normal finding and would not cause concern.

Which factors affect the process of labor and birth? Select all that apply. Birth canal Endogenous endorphins Contractions Blood glucose levels Fetus and placenta

Birth canal Contractions Fetus and placenta Rationale The birth canal is made up of the mother's rigid bony pelvis and soft tissues. The shape and size of the pelvis helps to assess the labor progress. The soft tissues of the birth canal aid in the vaginal birth of the fetus. The frequency, duration, and intensity of the uterine contractions cause cervical dilation and expulsion of the infant from the uterus and vagina. The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position determine how the fetus moves through the birth canal. The placenta also passes through the birth canal after the expulsion of the fetus. Endogenous endorphins produced by the body affect the perception of pain in the patient and not the birthing process. A decrease in blood glucose levels may occur during labor. However it is a normal endocrine change and does not affect the process of labor.

Subarachnoid (spinal) block

Block administered just before birth -Anesthetic relieves uterine and perineal pain and numbs vagina, perineum, and lower ext. -May cause maternal hypotention, Post pardum H/A Mother must lie flat for 8-12 hours after spinal injection.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe what? Weight gain of 1 to 3 lbs. Quickening. Fatigue and lethargy. Bloody show.

Bloody show. Rationale Passage of the mucus plug (operculum) also termed pink/bloody show occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

When assessing fetal heart rate, which patterns would be concerning to the nurse? Select all that apply. Bradycardia Accelerations Reccurent late declerations Absent baseline variability Recurrent variable decelerations

Bradycardia Bradycardia is nonreassuring and can be caused by fetal head compression, fetal hypoxia, fetal acidosis, fetal heart block, and umbilical cord compression. Reccurent late declerations Reccurent late decelerations are nonressuring and can be a sign of uteroplacental insufficency. Absent baseline variability The absence of baseline variability is nonreassuring and may indicate fetal hypoxia or central nervous system depression. Recurrent variable decelerations Recurrent variable decelerations are nonreassuring if the FHR falls to less than 60 bpm for more than 60 secs and may indicate umbilical cord compression.

The nurse is auscultating and documenting the fetal heart rate (FHR) of a client intermittently with a handheld Doppler device. Which terms are appropriate for the nurse to use while documenting the FHR? Select all that apply. Bradycardia Regular rhythm Moderate variability Variable deceleration Absence of acceleration

Bradycardia Regular rhythm Absence of acceleration Rationale Bradycardia is a baseline FHR less than 110 beats/minute for 10 minutes or longer. The nurse can use the term "bradycardia," which is numerically defined, when documenting the FHR. When the FHR is auscultated by handheld doptone, it should be described as a baseline number or range and as having a regular or irregular rhythm. The term "absence of acceleration" can also be used by the nurse documenting the FHR. The presence or absence of accelerations or decelerations, both during and after contractions, should also be noted. Descriptive terms associated with EFM such as "moderate variability" and "variable deceleration" cannot be used. They are visual descriptions of the patterns produced on the monitor tracing. The term "variable deceleration" cannot be used while documenting the FHR; it is a visually abrupt decrease in the FHR below the baseline.

A woman is brought into labor and delivery in the early stages of labor. Place the following breathing techniques in the order in which they should be implemented during the labor process. Cleansing breath Modified-pace breathing Pattern-paced breathing Slow-paced breathing

Breathing techniques begin with simple breathing patterns and progress to more complex ones as needed. Cleansing breaths (which help prevent myometrial hypoxia and labor pain) are used to start and end each contraction. Slow-paced breathing is used from the first stage of labor and as long as it is effective. When necessary, modified-paced breathing is used; these breaths are shallower but a bit faster. The focus is still on relaxation. Pattern-paced breathing (or "pant blow" breaths) are used in the last stage. After a number of breaths, the woman exhales with an emphasis on the exhale and then returns to modified-paced breathing again.

With regard to breathing techniques during labor, maternity nurses should be aware of what? Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction By the time labor has begun, it is too late for instruction in breathing and relaxation Controlled breathing techniques are most difficult near the end of the second stage of labor The patterned-paced breathing technique can help prevent hyperventilation

Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction Rationale First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

With regard to breathing techniques during labor, maternity nurses should be aware of what? Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction By the time labor has begun, it is too late for instruction in breathing and relaxation Controlled breathing techniques are most difficult near the end of the second stage of labor The patterned-paced breathing technique can help prevent hyperventilation

Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction Rationale First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

With regard to breathing techniques during labor, maternity nurses should be aware that: Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. By the time labor has begun, it is too late for instruction in breathing and relaxation. Controlled breathing techniques are most difficult near the end of the second stage of labor. The patterned-paced breathing technique can help prevent hyperventilation.

Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor, when the cervix is dilated 8 to 10 cm. Patterned-paced breathing can sometimes lead to hyperventilation.

Which fetal presentations can be seen during birth? Select all that apply. Breech Oblique Cephalic Shoulder Transverse

Breech Cephalic Shoulder Rationale Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor. The breech presentation means that the buttocks, feet, or both the buttocks and feet together will appear first. The cephalic presentation means that the fetal head will be the first part to appear through the birth canal. The shoulder presentation means that the presenting part is the scapula. The terms oblique and transverse refer to the fetal lie, in which the long axis of the fetus is at a right angle diagonal to the long axis of the mother.

Accelerations

Brief temp increases in FHR atleast 15bpm more than baseline lasting 15 sec Usually reasssuring= reflecting a responsive, nonacidotic fetus Occurs with fetal movement May occur with uterine contractions, vaginal exams, mild cord compression or fetus in breech presentation

Moxibustion

Burning lungwort close to acupuncture point 67, the tip of the fifth toe, has promising evidence for less need for oxytocin and fewer cesarean births. Noninvasive Safe way to correct malposition of fetus

Ring of fire

Burning sensation of acute pain as vagina stretches and crowning occurs

What should the nurse do if the fetus is tachycardic (higher than 160) or bradycardic (lower than 120) ?

Changed position of the mother, administer O2, and notify doctor or midwife.

Episodic Changes

Changes in fetal heart rate that are not associated with uterine contractions (includes both accelerations and decelerations)

Periodic Chang

Changes in fetal heart rate that occur with uterine contractions (includes both accelerations and decelerations)

What does the nurse teach the client about the benefits of breathing techniques in the second stage of labor? Does not interfere with fetal descent Causes increase in abdominal pressure Reduces discomfort during contractions Increases the size of the abdominal cavity

Causes increase in abdominal pressure Rationale In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent.

Which fetal presentation is ideal for labor? Cephalic Frank breech Complete breech Single-footed breech

Cephalic The fetal head is the largest single fetal part. After the head is born, the smaller parts follow easily as the extremities unfold.

Stage 1 (2. Active Phase)

Cervical dilation 4-7cm Contractions occur every 3-5 mins; 30-60 sec; mod intensity Interventions: encourage effective breathing, quiet environment, comfort, Effleurage (light stroking of abdomen), void 1-2 hours

Stage 1 (3. Transition phase)

Cervical dilation 8-10cm Contractions every 2-3 mins; 45-90 sec duration, strong intensity Interventions: rest b/w contractions, wake mother at beginning of contractions for breathing patterns, provide privacy, offer ice chips, void 1-2 hours.

Stage 2 Assessment

Cervical dilation is complete when stage 2 begins. Progress of labor is measured by descent of fetal head through the birth canal (change in fetal station). Uterine contractions occur every 2 to 3 minutes and last 60 to 75 seconds; the intensity is strong. Increase in bloody show occurs. Mother feels urge to bear down; assist mother in pushing efforts.

Which labor assessment finding best distinguishes between true and false labor? Cervical effacement and dilatation Mild discomfort felt in the abdomen and pelvis Contractions that subside with increased activity No significant change in cervical effacement or dilatation

Cervical effacement and dilatation The best distinction between the two is that the contractions of true labor cause progressive changes in the cervix. Effacement and dilatation occur with true labor contractions.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: Change in position. Oxytocin administration. Regional anesthesia. Intravenous analgesic.

Change in position. Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This pressure reduces venous return to the woman's heart, as well as cardiac output, and subsequently lowers her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration, regional anesthesia, and intravenous analgesic may all reduce maternal cardiac output.

Fetal bradycardia or tachycardia occurs

Change the position of the mother, admin oxygen and assess the mothers vital signs. Notify MD

When evaluating the external fetal monitor tracing of a woman whose labor is being induced, the nurse identifies signs of persistent late deceleration patterns and begins intrauterine resuscitation interventions. Which choice indi- cates that the following appropriate interventions were implemented in the recommended order of priority? 1. Increase rate of maintenance IV solution. 2. Palpate uterus for tachysystole. 3. Discontinue oxytocin (Pitocin) infusion. 4. Change maternal position to a lateral position, and then elevate her legs if woman is hypotensive. 5. Administer oxygen at 8 to 10 L/minute by nonrebreather face mask. A. 2, 1, 5, 4, 3 B. 4, 1, 2, 3, 5 C. 5, 3, 4, 1, 2 D. 4, 5, 1, 2, 3

Choice B is correct; see Box 18-5 for the rationale." (Lowdermilk 310) Lowdermilk, Deitra. Study Guide for Maternity and Women's Health Care, 11th Edition. Mosby, 2016. VitalBook file. B. 4, 1, 2, 3, 5

A nulliparous woman is in the active phase of labor and her cervix has progressed to 6 cm dilation. The nurse caring for this woman evaluates the external monitor tracing and notes the following: decrease in FHR shortly after onset of several uterine contractions returning to baseline rate by the end of the contraction; shape is uniform. Based on these findings, the nurse should: A. Change the woman's position to her left side B. Document the finding on the woman's chart C. Notify the physician D. Perform a vaginal examination to check for cord prolapse"

Choice B is correct; the pattern described is an early deceleration pattern, which is considered to be benign, requiring no action other than documentation of the finding; changing a woman's position and notifying the physician would be appropriate if abnormal (non- reassuring) signs such as late or variable decelerations were occurring; prolapse of cord is associated with variable decelerations as a result of cord compression." B. Document the finding on the woman's chart

A vaginal examination is performed on a multiparous woman who is in labor. The results of the examination were documented as 4 cm, 75%, +1, ROA. An accurate interpretation of these data is: A. Woman is in the latent phase of the first stage of labor B. Station is 1 cm above the ischial spines C. Presentation is cephalic D. Lie is transverse"

Choice C is correct; O, or occiput, indicates a vertex presentation with the neck fully flexed and the occiput in the right anterior pelvic segment (R, A) of the woman's pelvis; the station is 2 cm below the ischial spines (12); the woman is in the active phase of labor, as indicated by 4 cm of dilation, and effacement is 75%; the lie is longitudinal because the head (cephalic/vertex) is presenting." C. Presentation is cephalic

A woman's amniotic membranes have apparently ruptured. The nurse assesses the fluid to determine its character- istics and confirm membrane rupture. An expected assessment finding of membrane rupture is: A. pH 5.5 B. Absence of ferning C. Pale, clear fluid with white flecks D. Strong odor"

Choice C is correct; pH of amniotic fluid is alkaline at 6.5 or higher, ferning is noted when examining fluid with a microscope, and the fluid is relatively odorless; a strong odor is strongly suggestive of in- fection; white flecks indicate vernix caseosa." C. Pale, clear fluid with white flecks

A laboring woman's temperature is elevated as a result of an upper respiratory infection. The FHR pattern that reflects maternal fever is: A. Diminished variability B. Variable decelerations C. Tachycardia D. Early decelerations"

Choice C is correct; the FHR increases as the maternal core body temperature elevates; therefore tachycardia is the pattern exhibited; it is often a clue of intrauterine infection because maternal fever is often the first sign; diminished variability reflects hypoxia, variable decelerations are characteristic of cord compression, and early decelerations are characteristic of head compression by the cervix." C. Tachycardia

When instructing a group of primigravida women about the onset of labor, the nurse tells them to be alert for: A. Urinary retention B. Weight gain of 2 kg C. Quickening D. Energy surge"

Choice D is correct; quickening refers to the woman's first perception of fetal movement at 16 to 20 weeks of gestation; lightening accompanied by urinary frequency and weight loss of 0.5 to 1 kg occur to signal that the onset of labor is near; back- ache, stronger Braxton Hicks, and bloody show are also noted; see Box 16-1." D. Energy surge

A laboring woman's uterine contractions are being internally monitored. When evaluating the monitor tracing, which finding is a source of concern and requires further assessment? A. Frequency every 2 1⁄2 to 3 minutes B. Duration of 80 to 85 seconds C. Intensity during a uterine contraction of 85 to 90 mm Hg D. Average resting pressure of 20 to 25 mm Hg"

Choice D is correct; the average resting tone during labor should be 10 mm Hg; choices A, B, and C are all findings within the expected ranges." D. Average resting pressure of 20 to 25 mm Hg

A nurse caring for women in labor should be aware of signs characterizing normal (reassuring) and abnormal (nonreassuring) FHR patterns. What would be characteristic of abnormal patterns? (Circle all that apply.) A. Moderate baseline variability B. Average baseline FHR of 100 beats/minute C. Acceleration of the FHR with movement D. Late deceleration patterns approximately every three or four contractions E. FHR of 170 beats/minute between contractions F. Early deceleration patterns when the cervix is dilated to 7 cm"

Choices B, D, and E are correct; the baseline rate should be 110 to 160 beats/minute; accelerations should occur with fetal movement; no late deceleration pattern of any magnitude is normal (reassuring), especially if it is repetitive or uncorrectable; early deceleration patterns are expected findings when fetal head compression by the cervix occurs." B. Average baseline FHR of 100 beats/minute D. Late deceleration patterns approximately every three or four contractions E. FHR of 170 beats/minute between contractions

Frequency of Contractions

Contraction frequency ranges from 2- 5 per 10 minutes during labor, with lower frequencies seen in first stage and higher frequencies seen (up to 5 contractions in 10 minutes) seen during second stage of labor

Strong

Contraction presents with rigid border like fundus that is almost impossible to indent with fingertips (feels like pressing finger to forehead)

External electronic fetal monitoring will be used for a woman just admitted to the labor unit in active labor. Guidelines that the nurse should follow when implementing this form of monitoring are to: (Circle all that apply.) A. Use Leopold maneuvers to determine correct placement of the tocotransducer B. Assist the woman to maintain a dorsal recumbent position to ensure accurate monitor tracings that can be evaluated easily C. Apply contact gel to the ultrasound transducer prior to application over the point of maximum intensity of the FHR D. Reposition the tocotransducer when the fetus changes its position E. Caution the woman to avoid effleurage when the transducers are in place F. Palpate the fundus periodically to estimate the intensity of the uterine contractions"

Choices C and F are correct; Leopold maneuvers are used to locate the PMI for correct placement of the ultrasound transducer; the tocotransducer is al- ways placed over the fundus; the ultrasound trans- ducer's position needs to change with fetal move- ment; the tocotransducer cannot assess intensity of contractions; therefore periodic palpation is an es- sential assessment measure; effleurage can be used around the transducers or on other parts of the woman's body." C. Apply contact gel to the ultrasound transducer prior to application over the point of maximum intensity of the FHR F. Palpate the fundus periodically to estimate the intensity of the uterine contractions"

Oxytocic

Classification of medication that stimulates the uterus to contract (a uterotonic)."

When performing vaginal examinations on a laboring woman, the nurse should be guided by what principle? Cleanse the vulva and perineum before and after the examination as needed. Wear a clean glove lubricated with tap water to reduce discomfort. Perform the examination every hour during the active phase of the first stage of labor. Perform an examination immediately if active bleeding is present.

Cleanse the vulva and perineum before and after the examination as needed. Cleansing will reduce the possibility that secretions and microorganisms will ascend into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should be performed only as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present, because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

When performing vaginal examinations on laboring women, the nurse should be guided by what principle? Cleanse the vulva and perineum before and after the examination as needed. Wear a clean glove lubricated with tap water to reduce discomfort. Perform the examination every hour during the active phase of the first stage of labor. Perform an examination immediately if active bleeding is present.

Cleanse the vulva and perineum before and after the examination as needed. Rationale Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should only be performed as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. What should the nurse do in this situation? Administer terbutaline (Brethine) before the test. Collect blood from both umbilical artery and vein. First perform the fetal scalp stimulating technique. Only collect blood from the baby's umbilical artery.

Collect blood from both umbilical artery and vein. Rationale An umbilical cord acid-base determination test is performed to assess the immediate condition of the neonate after birth if there is an abnormal or confusing fetal heart rate (FHR) tracing found during the labor. The nurse should collect blood from both umbilical artery and umbilical vein in order to perform the test. Fetal scalp stimulating technique is an indirect method to assess the fetal blood pH. This test need not be performed prior to this acid-base determination test. It is not necessary to administer terbutaline (Brethine) before performing the test; it is administered during the time of labor if uterine contractions (UCs) are too frequent.

What are signs of potential complications of labor? Contractions lasting 90 seconds or longer Urine-smelling vaginal discharge Irregular fetal heart rate (FHR); suspected fetal arrhythmias More than five contractions in a 5-minute period Relaxation between contractions lasting shorter than 30 seconds Intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC])

Contractions lasting 90 seconds or longer Irregular fetal heart rate (FHR); suspected fetal arrhythmias More than five contractions in a 5-minute period Relaxation between contractions lasting shorter than 30 seconds Intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC]) Rationale Signs of potential complications of labor include contractions lasting 90 seconds or longer; irregular FHR and suspected fetal arrhythmias; relaxation between contractions lasting shorter than 30 seconds; and intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with IUPC). Foul-smelling (not urine-smelling) vaginal discharge, and more than five contractions in a 10-minute (not 5-minute) period (contractions occurring more frequently than every 2 minutes) are also signs of potential complications of labor.

Signs of False Labor:

Contractions: irregular (temporary regularity), often stop with walking/position change, felt in back or in abdomen above umbilicus, can be stopped with comfort measures Cervix: may be soft but with no significant changes in effacement or dilation or evidence of bloody show, posterior position Fetus: presenting part is not engaged

Signs of True Labor:

Contractions: regular, stronger, last longer, close together, more intense with walking, felt in lower back, radiate to lower portion of abdomen, continue despite comfort measures Cervix: progressive change (softening, dilation, effacement), moves to an increasingly anterior position Fetus: presenting part usually becomes engaged in the pelvis, increased ease of breathing, compresses bladder

What intervention does the nurse perform to provide a relaxed environment for labor? Stand at the bedside. Encourage rapid birth. Control sensory stimuli. Demonstrate excitement.

Control sensory stimuli. Rationale The nurse must assist the client by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the client's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the client for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the client.

Which is a characteristic of typical labor contractions? Localized Coordinated Can be initiated by the woman Mild discomfort felt in the abdomen and groin

Coordinated During true labor, a consistent and coordinated pattern of contractions with increasing frequency, duration, and intensity usually develops.

The nurse observes variable decelerations on the EFM and notices that the decrease is less than 60 bpm for more than 60 sec and does not quickly return to baseline. Which fetal compromise could be occurring? Cord compression Fetal head compression Uteroplacental insufficiency No compromise; normal variable decelerations

Cord compression Variable decelerations that last long and do not quickly return to the baseline can occur with cord compression, which could compromise the fetus.

A woman is experiencing back labor and complains of constant, intense pain in her lower back. What is an effective relief measure? Counterpressure against the sacrum Pant-blow (breaths and puffs) breathing techniques Effleurage Biofeedback

Counterpressure against the sacrum Rationale Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is what? Counterpressure against the sacrum Pant-blow (breaths and puffs) breathing techniques Effleurage Biofeedback

Counterpressure against the sacrum Rationale Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: Counterpressure against the sacrum. Pant-blow (breaths and puffs) breathing techniques. Effleurage. Biofeedback.

Counterpressure against the sacrum. Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain but it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

The nurse is providing care for a pregnant client in labor. Which interventions does the nurse implement to improve the client's environment? Create a home-like setting. Provide space for movement. Allow a lot of visitors in the room. Include the client's favorite foods in the diet. Facilitate easy access to showers.

Create a home-like setting. Provide space for movement. Facilitate easy access to showers. Rationale The nurse creates a home-like setting for the woman in labor to make her comfortable and facilitate a better labor and birth experience. The environment should have enough space to enable movement, position changes, and ambulation. Showers, tubs, and comfortable chairs should be readily available for various nonpharmacologic pain relief measures. The nurse ensures that the visitors in the client's room are limited, as per the hospital policies. The nurse will include only the prescribed foods in the client's diet.

Match the type of labor pain with its cause.

Pain caused by decreased blood flow to the uterus Tissue ischemia Pain caused by the stretching of the lower uterus Cervical dilation Pain caused by strain on ligaments and the peritoneum Pressure and pulling on pelvic structures Pain described as burning, tearing, or splitting of the vagina Distention of the vagina and perineum

Which cardinal movement of labor is crucial to the success of labor and must occur before all others? Flexion Descent Expulsion Engagement

Descent Descent of the fetus is a mechanism of labor that accompanies all the others. Without descent, none of the mechanisms will occur.

Which description of the phases of the second stage of labor is accurate? Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration vari Rationale The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Which description of the phases of the second stage of labor is accurate? Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down" period, at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Intensity of Contractions

Described as mild, moderate, or strong

What are the functions of the primary powers in the labor process? Select all that apply. Dilation of the cervix Descent of the fetus Effacement of the cervix Raise the pain threshold Expulsion of the infant from the uterus

Dilation of the cervix Descent of the fetus Effacement of the cervix Expulsion of the infant from the uterus Rationale The primary powers efface and dilate the cervix at the onset of labor. Dilation refers to the enlargement of the cervical opening. The diameter of the cervix increases from less than 1 cm to 10 cm. The primary powers increase UCs that help in the descent of the fetus. Effacement refers to the shortening and thinning of the cervix during the first stage of labor. The primary powers along with the secondary powers are used in the expulsion of the infant from the uterus. Endogenous endorphins that are naturally produced by the body raise the pain threshold in the patient.

The nurse notes a pattern of late decelerations on the fetal monitor. Which are the appropriate nursing actions? Select all that apply. Discontinue oxytocin. Provide water to the mother. Administer oxygen by facemask. Reposition the mother onto her side. No nursing actions are needed at this time.

Discontinue oxytocin. Discontinuing the oxytocin will decrease the effect of uterine stimulants on the contractions. Administer oxygen by facemask. Oxygen increases the oxygenation to the mother, which, in turn, perfuses the placenta as well. Correct Reposition the mother onto her side. Repositioning the mother on her side, rather than allowing a supine position, is preferred. A supine position increases pressure on the vena cava, which reduces the blood supply, causing decreased perfusion of the placenta.

Fetal Monitoring

Displays fetal heart rate (FHR) Used to monitor uterine activity Used to assess frequency, duration, and intensity of contractions Used to assess FHR in relation to maternal contractions Baseline FHR measured between contractions; normal FHR at term is 120 to 160 beats/min

Causes of late decelerations

Disrupted oxygen transfer to fetus due to: -maternal hypotension -uterine tachysystole (more than 5 contractions in 19 minutes averaged)- most common Cause due to administration of pitocin -preeclampsia -late term or postterm pregnancy -amnionitis -small for gestational age fetus -maternal diabetes -placenta previa -placental abruption -conduction anesthetics -maternal cardiac disease -maternal anemia

The nurse is teaching pain relief techniques to a group of expectant clients. What does the nurse teach the clients about the gate-control theory of pain? Distractions block the nerve pathways. Neuromuscular activity can increase pain. All sensations travel together to the brain. Motor activity during labor intensifies pain

Distractions block the nerve pathways. Rationale The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetical gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain.

The nurse is teaching pain relief techniques to a group of expectant clients. What does the nurse teach the clients about the gate-control theory of pain? Distractions block the nerve pathways. Neuromuscular activity can increase pain. All sensations travel together to the brain. Motor activity during labor intensifies pain.

Distractions block the nerve pathways. Rationale The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetical gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain.

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? Pallor Nausea Dizziness Diaphoresis

Dizziness Rationale The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.

The nurse is palpating for uterine activity during intermittent auscultation (IA) for a client in labor. What interventions does the nurse perform? Select all that apply. Place a scope over the fundus to assess resting tone. Document the uterine resting tone as either hard or soft. Place a hand over the fundus during the contractions. Measure the uterine contraction duration in seconds. Measure the uterine contraction frequency in minutes.

Document the uterine resting tone as either hard or soft. Place a hand over the fundus during the contractions. Measure the uterine contraction duration in seconds. Measure the uterine contraction frequency in minutes. Rationale The nurse assesses the resting tone, or relaxation between contractions, and documents the uterine resting tone as hard or soft. The duration of a uterine contraction, from the beginning to the end of the contraction, is measured in seconds. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next contraction. The nurse assesses the resting tone by placing a hand, not a scope, over the fundus after the contraction is over. The nurse places fingertips or a hand over the fundus before, during, and after the contraction. This helps the nurse assess the intensity, duration, and frequency of the contractions.

Which techniques can a pregnant client use to reduce her perception of pain during labor? Select all that apply. Drinking herbal tea Reciting prayers Bathing with cold water Using attention-focusing techniques Using breathing techniques

Drinking herbal tea Reciting prayers Using attention-focusing techniques Using breathing techniques Rationale Drinking herbal tea during labor may help the client relax, reduce nausea and fatigue, and help to maintain fluid balance. Attention-focusing is a distraction technique that helps relieve labor pain. The client can focus her attention on any object in the labor room during contractions and use breathing techniques while focusing on the object to reduce her perception of the pain. The nurse can encourage the client to recite prayers, to provide some degree of emotional comfort and pain relief, depending on the client's religious beliefs. The client can also use a hand-held warm water shower, rather than a cold-water shower, to relieve labor pain.

Which techniques can a pregnant client use to reduce her perception of pain during labor? Select all that apply. Drinking herbal tea Reciting prayers Bathing with cold water Using attention-focusing techniques Using breathing techniques

Drinking herbal tea Reciting prayers Using attention-focusing techniques Using breathing techniques Rationale Drinking herbal tea during labor may help the client relax, reduce nausea and fatigue, and help to maintain fluid balance. Attention-focusing is a distraction technique that helps relieve labor pain. The client can focus her attention on any object in the labor room during contractions and use breathing techniques while focusing on the object to reduce her perception of the pain. The nurse can encourage the client to recite prayers, to provide some degree of emotional comfort and pain relief, depending on the client's religious beliefs. The client can also use a hand-held warm water shower, rather than a cold-water shower, to relieve labor pain.

While monitoring the fetal heart rate (FHR) of a client, the nurse notes tachycardia. What is a probable cause for this condition? Early signs of fetal distress Maternal hypothermia Maternal hypoglycemia Atrioventricular dissociation

Early signs of fetal distress Rationale Tachycardia is a baseline FHR greater than 160 beats/minute that lasts for 10 minutes or longer. It may be considered an early sign of fetal distress or even fetal hypoxemia, especially when associated with late decelerations and minimal or absent variability. It can result from maternal or fetal infection. Bradycardia is a baseline FHR less than 110 beats/minute that lasts for 10 minutes or longer. Maternal hypothermia or maternal hypoglycemia may cause bradycardia. Bradycardia, not tachycardia, is often caused by some type of fetal cardiac problem. These may include structural defects involving the conduction system, as in atrioventricular dissociation.

With regard to systemic analgesics administered during labor, nurses should be aware of what? Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier Effects on the fetus and newborn can include decreased alertness and delayed sucking IM administration is preferred over IV administration IV patient-controlled analgesia (PCA) results in increased use of an analgesic

Effects on the fetus and newborn can include decreased alertness and delayed sucking Rationale Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

With regard to systemic analgesics administered during labor, nurses should be aware that: Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. Effects on the fetus and newborn can include decreased alertness and delayed sucking. IM administration is preferred over IV administration. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

Effects on the fetus and newborn can include decreased alertness and delayed sucking. Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

Which action, taken by the patient, will reduce discomfort during Leopold's Maneuvers and make fetal presenting parts easier to feel? Standing Lying prone Emptying the bladder Pushing or bearing down with contractions

Emptying the bladder Emptying the bladder reduces discomfort during palpation and makes fetal parts easier to feel.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? The healthy newborn should be taken to the nursery for a complete assessment. After drying, the infant should be given to the mother wrapped in a receiving blanket. Encourage skin-to-skin contact of mother and baby. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

Encourage skin-to-skin contact of mother and baby.

Which nursing intervention is useful for a client in labor to reduce intrathoracic pressure and prevent fetal hypoxia? Encourage the client to take deep, cleansing breaths and relax. Encourage the client to exhale, holding her breath for short periods. Encourage the client to position herself comfortably. Encourage the client to push when she feels the urge to bear down

Encourage the client to exhale, holding her breath for short periods. Rationale The nurse should encourage the client to exhale after holding her breath for short periods. This prevents a sudden increase in the client's intrathoracic pressure and prevents fetal hypoxia. Encouraging the client to take deep, cleansing breaths and relaxing between contractions helps reduce fatigue and increase the effectiveness of pushing efforts during labor. Encouraging the client to maintain a comfortable position during labor facilitates the labor process. Encouraging the client to push when she perceives the urge to bear down helps aid in the descent and rotation of the fetus.

A primigravida at 40 weeks' gestation is admitted to the labor unit in latent labor. Her prenatal history does not indicate any risk factors. Her initial vital signs are temperature of 37.1°C (98.8°F); pulse, 86 bpm; respirations, 20; and blood pressure, 114/68 mm Hg. She has been connected to external electronic monitoring for 1 hour. FHR baseline is 145 with moderate variability, the presence of accelerations, and absence of decelerations. She is having contractions every 3 to 4 minutes, each lasting 40 to 60 seconds, mild to palpation, and with soft resting tone. What is an appropriate nursing intervention at this point? Encourage the patient to ambulate within the labor unit. Have the patient eat a high-carbohydrate meal. Request a sleeping pill for the patient. Encourage the patient to accept parenteral analgesia.

Encourage the patient to ambulate within the labor unit.

voiding in labor

Encourage voiding every __ hours. A distended bladder may impede descent of the presenting part, slow or stop uterine contractions, and lead to decreased bladder tone or uterine atony after birth. Most women do not have bowel movements during labor because of decreased intestinal motility Stool that has formed in the large intestine often moves downward toward the anorectal area as a result of pressure exerted by the fetal presenting part as it descends. This stool is often expelled during the second-stage pushing and birth. NORMAL AND EXPECTED Routine use of __ may lower infection rates and the newborns have fewer lower respiratory tract infections and less need for antibiotics, however, they cause discomfort for women and increase the costs of giving birth -- benefits do not outweigh the risks If a woman expresses the urge to defecate_, the nurse should perform a vaginal examination to assess cervical dilation and station. When a multiparous woman experiences this, this often means birth will follow.

In the current practice of childbirth preparation, emphasis is placed on: The Dick-Read (natural) childbirth method. The Lamaze (psychoprophylactic) method. The Bradley (husband-coached) method. Encouraging expectant parents to attend childbirth preparation in any or no specific method.

Encouraging expectant parents to attend childbirth preparation in any or no specific method. Encouraging expectant parents to attend class is most important, because preparation increases a woman's confidence and thus her ability to cope with labor and birth. The goal is to encourage new parents to attend any one of the acceptable childbirth education programs. Gaining in popularity are Birthing from Within and Hypnobirthing. The Dick-Read method is historically popular and is still in use. The Lamaze method is less focused on a method approach and more concerned with psychologic preparation for labor. Attendance at any available class should be encouraged, however. Bradley as well as other methods encourage women to choose the techniques that work best for them. Women are helped to develop their own birth philosophy and then choose from a variety of skills to help cope with the labor process.

Which nursing intervention is important when providing care for a pregnant client in the first stage of the labor? Determining the station Obtaining an order for epidural anesthesia Encouraging the client to hold breath and tighten abdominal muscles Encouraging the client to change position frequently

Encouraging the client to change position frequently Rationale In the first stage of labor, the pregnant client may experience fatigue and discomfort. Therefore, the nurse instructs the client to change position frequently to relieve fatigue, increase comfort, and improve circulation. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Epidural anesthesia is administered only if the labor is prolonged and the client is unable to tolerate pain. The client may tighten the abdominal muscles or hold her breath in the second stage of labor. However, the nurse should advise the client against it to prevent fetal hypoxia.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include which actions? Encouraging the woman to try various upright positions, including squatting and standing Telling the woman to start pushing as soon as her cervix is fully dilated Continuing an epidural anesthetic so that pain is reduced and the woman can relax Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

Encouraging the woman to try various upright positions, including squatting and standing Rationale Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: Encouraging the woman to try various upright positions, including squatting and standing. Telling the woman to start pushing as soon as her cervix is fully dilated. Continuing an epidural anesthetic so that pain is reduced and the woman can relax. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

Encouraging the woman to try various upright positions, including squatting and standing. Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. An epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

The nurse is using heat and cold applications to reduce pain in a pregnant client during labor. What precautions does the nurse take? Ensures that heat and cold are used alternately Avoids cold packs on areas of musculoskeletal pain Avoids hot or cold application over anesthetized areas Avoids applying cold packs on the client's face during active labor Places two layers of cloth between the skin and the hot pack

Ensures that heat and cold are used alternately Avoids hot or cold application over anesthetized areas Places two layers of cloth between the skin and the hot pack Rationale The nurse ensures that hot and cold packs are used alternately on the client's skin to achieve greater pain relief. The nurse avoids heat or cold application over anesthetized areas, because tissues can be damaged. The nurse places two layers of cloth between the skin and the hot or cold packs to avoid damaging the underlying integument. Using cold packs on areas of musculoskeletal pain is helpful, because it helps reduce muscle temperature and relieve muscle spasms. Applying cold packs on the client's face during active labor helps increase her comfort.

epidural block

Epidural block - injection of local anesthetic or opioid agent or both into the fourth and fifth lumbar vertebrae Local anesthetic agent:bupivacaine, ropivacaine Opioid analgesic: fentanyl, sufentanil

Which changes in the maternal estrogen to progesterone level signal the onset of labor? Estrogen levels are equal to progesterone levels. Estrogen levels are lower than progesterone levels. Estrogen levels are higher than progesterone levels. There is no significant change in ratio of estrogen to progesterone

Estrogen levels are higher than progesterone levels. Estrogen levels equal to progesterone prevent contractions to occur.

The nurse instructs a pregnant client to breathe through the mouth and keep it open while pushing during labor. What is the rationale for this nursing intervention? Avoiding nasal congestion in the client To decrease efforts required for pushing Facilitating increased oxygen to the fetus To avoid deceleration in fetal heart rate

Facilitating increased oxygen to the fetus Rationale During labor the nurse asks the client to breathe through the mouth to keep her mouth open to increase both maternal and fetal oxygenation. Nasal congestion is not a complication associated with labor. Opening of the mouth does not increase the pushing capability. Early decelerations are observed by pushing, which does not require any intervention.

Which fetal and maternal physiologic conditions does the nurse assess during the first stage of labor? Select all that apply. Fetal heart rate Fetal circulation Maternal heart rate Maternal Valsalva maneuver Maternal supine hypotension

Fetal heart rate Fetal circulation Maternal heart rate Rationale The nurse assesses fetal heart rate to evaluate oxygen demands. Maternal position, uterine contractions, blood pressure, and umbilical cord blood flow may affect fetal circulation. There is a drop in the maternal heart rate during labor and the nurse should monitor it to be alert to any complications. The Valsalva maneuver may be seen in the patient during the second stage of labor. The client may hold her breath and tighten the abdominal muscles for pushing. Supine hypotension may be seen in the client during labor if the uterus is large or the client is obese or hypovolemic.

Which parameter should be closely monitored in a patient during the latent phase of the first stage of labor? Fetal heart rate Cervical dilation Maternal temperature External cephalic version

Fetal heart rate Rationale During the first stage of labor, uterine contractions have just begun and the fetus is monitored for various parameters. The fetal heart rate is monitored atleast every 30 to 60 minutes to ensure the safety of the fetus. Cervical dilation is assessed through vaginal examination and helps to determine the approximate time required for delivery. Maternal temperature is monitored every 2 to 4 hours to ensure the patient's safety. External cephalic version is performed to align the fetus to the birth canal.

Which describes moderate variability of the fetal heart rate? Fetal heart rate is 100 bpm for 15 minutes. Fetal heart rate fluctuates, with an average of 12 bpm. Fetal heart rate at baseline has a smooth, flat appearance at 2 beats per minute. Fetal heart rate accelerates 25 bpm above baseline with a duration of 20 seconds

Fetal heart rate fluctuates, with an average of 12 bpm. A fluctuating fetal heart rate of 6-25 beats per minute is considered moderate variability and is normal and reassuring.

When monitoring a woman in labor who has just received spinal analgesia, which assessment findings should the nurse report to the health care provider? Select all that apply. Maternal blood pressure of 108/79 Maternal heart rate of 98 Respiratory rate of 14 breaths/min Fetal heart rate of 100 beats/min Minimal variability on a fetal heart monitor

Fetal heart rate of 100 beats/min Minimal variability on a fetal heart monitor Rationale After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or absent variability, late decelerations) develop, emergency care must be given.

The nurse notes that a woman's temperature is 100.7° F. Which fetal heart rate finding is expected as a result of the increased maternal temperature? No expected changes Prolonged decelerations Fetal heart rate of 90 bpm for 15 minutes Fetal heart rate of 180 bpm for 12 minutes

Fetal heart rate of 180 bpm for 12 minutes A maternal fever can directly increase the fetal temperature or infect the fetus in cases of infection. The fetus responds with an increased heart rate and can be the cause of fetal tachycardia.

Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will not affect fetal circulation during labor? Fetal position Uterine contractions Blood pressure Umbilical cord blood flow

Fetal position Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow. Uterine contractions during labor tend to decrease circulation and subsequent perfusion. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Maternal blood pressure is likely to have a significant effect on fetal circulation. Compression of the cord and reduction of umbilical blood flow do affect fetal circulation.

The most common cause of decreased variability in the FHR that lasts 30 minutes or less is what? Altered cerebral blood flow Fetal hypoxemia Umbilical cord compression Fetal sleep cycles

Fetal sleep cycles Rationale A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow results in early decelerations in the FHR. Fetal hypoxemia is evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. Umbilical cord compression results in variable decelerations in the FHR.

The most common cause of decreased variability in the FHR that lasts 30 minutes or less is: Altered cerebral blood flow. Fetal hypoxemia. Umbilical cord compression. Fetal sleep cycles.

Fetal sleep cycles. A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow results in early decelerations in the FHR, and umbilical cord compression in variable decelerations. Fetal hypoxemia is evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be s

The nurse caring for the woman in labor understands that absent (or minimal) variability is considered nonreassuring. However, which condition, related to decreased variability, is considered benign? Drug effects CNS depressants Fetal sleep episodes Local anesthetic agents

Fetal sleep episodes Fetal sleep episodes are non benign causes of absent baseline variability. The episodes are usually 40 minutes or less and happen occasionally.

The diagnostic test reports of a pregnant client reveal a baseline fetal heart rate of 175 beats/minute. What does this finding indicate to the nurse? Presence of fetal ischemia. Fetal tachycardia. Fetal bradycardia. The fetus has hypotension.

Fetal tachycardia. Rationale Normal baseline fetal heart rate ranges from 110 to 160 beats/minute. If the fetal heart rate is more than 160 beats/minute, then tachycardia in the fetus is indicated. Ischemia is a condition in which there is a reduced blood supply to the fetal tissues. Baseline heart rate below 110 beats/minute indicates bradycardia in fetus. Hypotension indicates a blood pressure level below 120/80 mm Hg, which is a life-threatening condition for the fetus.

Which of the following statements is used to describe a characteristic of a uterine contraction? Select all that apply. Frequency (how often contractions occur) Intensity (the strength of the contraction at its peak) Resting tone (the tension in the uterine muscle between contractions) Appearance (shape and height) Attitude (the way the uterus presents itself)

Frequency (how often contractions occur) Intensity (the strength of the contraction at its peak) Resting tone (the tension in the uterine muscle between contractions) Rationale Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not a term used to describe contractions. Duration is another characteristic of uterine contractions. Uterine contractions are described in terms of frequency or how often the contractions occur. Uterine contractions are described in terms of intensity (the strength of the contraction at its peak). Uterine contractions are described in terms of resting tone (the tension in the uterine muscle) or attitude (the way the uterus presents itself).

position of laboring woman

Frequent changes in position relieves fatigue, increases comfort, and improves circulation. Laboring woman should be encouraged to find positions most comfortable to her

Ferning

Frondlike crystalline pattern created by amniotic fluid when it is placed on a glass slide.

Positives of an upright birthing position (standing, sitting, kneeling, squatting, walking)

Gravity can promote the descent of the fetus Uterine contractions are generally stronger and more efficient in effacing and dilating the cervix Shorter labor Increasing perfusion to the uterus Less pain and perineal drainage Fewer episiotomies and abnormal FHR patterns, and fewer operative births

Which condition often occurs in a nulliparous client in contrast with a multiparous client during labor? An increase in the speed of fetal descent Less fatigue and pain due to a short labor Greater sensory labor pain during easy labor Greater sensory pain in the second stage of labo

Greater sensory labor pain during easy labor Rationale A nulliparous client may experience greater sensory labor pain during easy labor as compared to a multiparous client. This is because her reproductive tract structures are less flexible. The firmer tissues in nulliparous clients as compared to the flexible tissues in multiparous clients result in a gradual fetal descent. A nulliparous client has a longer labor and therefore experiences greater fatigue. A rapid fetal descent in the second stage of labor occurs in multiparous clients and causes greater sensory pain.

Which pelvic shape is the most classic female pelvis shape and most conducive to vaginal labor and birth? Android Gynecoid Platypelloid Anthropoid

Gynecoid Rationale The gynecoid pelvis is round and cylinder shaped, with a wide pubic arch. Prognosis for vaginal birth is good. Only 23% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The platypelloid pelvis is flat, wide, short, and oval. The anthropoid pelvis is a long, narrow oval with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: Either hot or cold applications may provide relief, but they should never be used together in the same treatment. Acupuncture can be performed by a skilled nurse with just a little training. Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. Therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should do what? Notify the woman's physician Tell the woman to slow the pace of her breathing Administer oxygen via a mask or nasal cannula Help her breathe into a paper bag

Help her breathe into a paper bag Rationale Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Notification of the physician is not necessary. Slowing the pace of her breathing will not correct the problem. Once the pattern of breathing is corrected her partner can help the woman maintain her breathing rate with visual, tactile or auditory cues. Administration of oxygen by either route will not resolve these symptoms.

Which internal monitoring device is used to measure uterine tone during and between contractions? IUPC Fetoscope Tocodynamometer Fetal scalp electrode

IUPC The IUPC is the internal monitoring device that is able to assess the intensity and resting tone of the contractions.

nursing interventions/IV

IV fluids are given to maintain __hydration In most cases, an electrolyte solution without glucose is adequate and does not introduce excess glucose into the bloodstream (LR, NS) IV fluids Excessive maternal glucose levels result in fetalhyperglycemia_ and hyperinsulism IV maternal infusions containing glucose can also reduce sodium levels in the woman and fetus, leading to transient neonatal tachypnea

Nonreassuring FHR pattern interventions

Identify cause (bradycardia, tachycardia, late decelerations, prolonged decelerations, hypertonic uterine activity, decreased/absent variability, variable desceleration <70 longer than 1 min) D/C oxytocin (Pitocin) infusion Change mothers position Admin oxygen 8-10Lm via mask IV fluids Initiate cont electronic fetal monitoring with internal devices Prepare for c-section

semirecumbent

If the __ position is used, do not force the woman's legs against her abdomen as she bears down. This position will increase perineal stretching and the risk for perineal trauma as well as spinal and lower extremity neurologic injuries

turn women to side oxygen administration by non-rebreather mask (10L/min)

If the baseline FHR declines, if absent or minimal variability occurs, or if decelerations patterns develop initiate these interventions:

squat

If the fetus is in the occiput posterior position, it may be helpful to encourage the woman to __ during contractions because this position increases the pelvic diameter, allowing the head to rotate to a more anterior position.

A woman is experiencing intense pain with each contraction during labor. Her partner asks her to describe in detail her favorite beach. Which relaxation technique is her husband utilizing? Imagery Focal point Acupressure Thermal stimulation

Imagery Describing in vivid detail the location of a pleasant destination is an example the use of imagery and an example of mental stimulation. Imagery can help a laboring woman dissociate herself from the painful aspects of labor.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. Imagine breathing in light and energy. Maintain clenched fists to drive out pain. Engage in dance or rhythmic movements. Imagine walking through a restful garden. Envisaging breathing out worries and tension.

Imagine breathing in light and energy. Imagine walking through a restful garden. Envisaging breathing out worries and tension. Rationale Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. Imagine breathing in light and energy. Maintain clenched fists to drive out pain. Engage in dance or rhythmic movements. Imagine walking through a restful garden. Envisaging breathing out worries and tension.

Imagine breathing in light and energy. Imagine walking through a restful garden. Envisaging breathing out worries and tension. Rationale Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

What are the differences between true and false labor? There are no differences between true and false labor. The differences between true labor and false labor include: true labor—contractions occur quickly, vaginal exam reveals appearance of bloody show, and the head of the fetus is visible in the pelvis. False labor—contractions are slow, vaginal exam has some bloody show, and the fetus is not visible in the pelvis. In true labor, contractions occur irregularly; they can be felt in the back or abdomen; the cervix may be soft, but there is no effacement or dilation; and the fetus is not engaged in the pelvis. In false labor, contractions occur regularly, become stronger, last longer, and occur closer together; they are usually felt in the lower back; the vaginal exam shows softening, effacement, and dilation by appearance of bloody show; and the fetus becomes engaged in the pelvis. In true labor, contractions occur regularly, become stronger, last longer, and occur closer together; they are usually felt in the lower back; the vaginal exam shows softening, effacement, and dilation by appearance of bloody show; and the fetus becomes engaged in the pelvis. In false labor, contractions occur irregularly; they can be felt in the back or abdomen; the cervix may be soft, but there is no effacement or dilation; and the fetus is not engaged in the pelvis.

In true labor, contractions occur regularly, become stronger, last longer, and occur closer together; they are usually felt in the lower back; the vaginal exam shows softening, effacement, and dilation by appearance of bloody show; and the fetus becomes engaged in the pelvis. In false labor, contractions occur irregularly; they can be felt in the back or abdomen; the cervix may be soft, but there is no effacement or dilation; and the fetus is not engaged in the pelvis. Rationale The differences between true and false labor include the following: In true labor, contractions occur regularly, become stronger, last longer, and occur closer together; they are usually felt in the lower back; the vaginal exam shows softening, effacement, and dilation by the appearance of bloody show; and the fetus becomes engaged in the pelvis. In false labor, contractions occur irregularly; they can be felt in the back or abdomen; the cervix may be soft, but there is no effacement or dilation; and the fetus is not engaged in the pelvis. There are definite differences between true and false labor.

Category II Fetal Heart Rate Classification

Include all tracings not categorized as Category I or Category III such as Baseline rate -either tachycardia or -bradycardia not accompanied by absent baseline variability Baseline FHR variability -minimal baseline variability -absent baseline variability not accompanied by recurrent decelerations -marked baseline variability Accelerations -no acceleration produced in response to fetal stimulation -periodic or episodic decelerations -recurrent variable decelerations accompanied by minimal or moderate baseline variability -prolonged decelarations (>2 minutes but <10 minutes) -recurrent late decelrations with moderate baseline variability -variable decelerations with other characteristics such as slow return to baseline, "overshoots" or "shoulders"

Which are the factors that affect the onset of labor? Increasing intrauterine pressure Increasing estrogen levels Decreasing oxytocin levels Decreasing progesterone levels Decreasing prostaglandin levels

Increasing intrauterine pressure Increasing estrogen levels Decreasing progesterone levels Rationale Increasing intrauterine pressure, increasing estrogen levels, and decreasing progesterone levels affect the onset of labor. Increasing intrauterine pressure is associated with increasing myometrial irritability. This is caused by increasing concentrations of estrogen and decreasing progesterone levels. Oxytocin and prostaglandin levels are known to increase during the onset of labor.

A nurse is caring for a patient who has a contraindication for spinal anesthesia. Which is a contraindication for spinal anesthesia? Allergy to naloxone Corrected hypovolemia History of sciatic nerve pain Infection at the site of insertion

Infection at the site of insertion Contraindications and precautions include the woman's refusal, coagulation defects, uncorrected hypovolemia, infection in the area of insertion, systemic infection, allergy, or possibly prior spinal surgery.

In the active phase of labor, how does the fetus typically reposition after effacement and dilatation of the cervix are complete? Extension begins Expulsion occurs Internal rotation occurs External rotation of the head occurs

Internal rotation occurs Internal rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis.

Which assessment findings would be present in a patient having hypertonic contractions? Select all that apply. Frequency every 2-3 min Duration between 40-60 seconds Intervals shorter than 30 seconds Durations longer than 90-120 seconds >30 seconds of complete relaxation of the uterus between contractions

Intervals shorter than 30 seconds Hypertonic contractions occur at intervals less than two minutes, reducing placental blood flow by prolonged compression of vessels that supply the intervillous spaces. Correct Durations longer than 90-120 seconds Hypertonic contractions last longer than 90-120 seconds, reducing placental blood flow by prolonged compression of vessels that supply the intervillous spaces.

A pregnant client complains of low back pain during labor. Which intervention will the health care team implement? Barbiturates Biofeedback Hydrotherapy Intradermal water block

Intradermal water block Rationale An intradermal water block is 0.05 to 0.1 ml of sterile water injected in four locations on the lower back to relieve low back pain. Barbiturates help relieve labor pains in the prolonged latent phase of labor. Biofeedback helps control body responses and functions and intensifies relaxation responses. Hydrotherapy is used to relieve pain during active labor and to avoid prolonged labor.

The nurse is caring for a client in the first stage of labor. Which nerve segments transmit pain impulses during this stage? Select all that apply. Lumbar spinal nerve segment L1 Pudendal nerve through S2 to S4 T10 to T12 spinal nerve segments Parasympathetic nervous system Upper lumbar sympathetic nerves

Lumbar spinal nerve segment L1 T10 to T12 spinal nerve segments Upper lumbar sympathetic nerves Rationale Pain impulses during the first stage of labor are transmitted via the T10 to T12 and L1 spinal nerve segments, and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix. Pain impulses during the second stage of labor are transmitted through the pudendal nerve through S2 to S4 spinal nerve segments and the parasympathetic system.

What precautions does the nurse take while providing care for a pregnant client during hydrotherapy? Select all that apply. Maintain water temperature at 36° to 37° C. Assist the client while she gets in and out of the tub. Use a handheld showerhead for cold application. Ensure that the water covers the client's abdomen. Ensure that the client's shoulders are under the water.

Maintain water temperature at 36° to 37° C. Assist the client while she gets in and out of the tub. Ensure that the water covers the client's abdomen. Rationale The nurse ensures that the water temperature during hydrotherapy is 36° to 37° C for maximum pain relief. The nurse assists the client while she gets in and out of the tub to prevent falls or accidents. The water should cover the client's abdomen to gain the maximum effect from the hydrostatic pressure and buoyancy of the water. The nurse provides a handheld showerhead for applying heat, not cold, to areas of discomfort. The client's shoulders need to be above the water to facilitate the dissipation of heat.

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? Meperidine (Demerol) Promethazine (Phenergan) Butorphanol tartrate (Stadol) Nalbuphine (Nubain)

Meperidine (Demerol) Rationale Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Nubain is an opioid agonist-antagonist analgesic.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by what? Narcotics Barbiturates Methamphetamines Tranquilizers

Methamphetamines Rationale The use of illicit drugs such as cocaine or methamphetamines might cause increased variability. Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates may also result in a significant decrease in variability, because these are known to cross the placental barrier. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: Narcotics. Barbiturates. Methamphetamines. Tranquilizers.

Methamphetamines. The use of illicit drugs such as cocaine or methamphetamines might cause increased variability. Maternal ingestion of narcotics and tranquilizer use may be the causes of decreased variability. The use of barbiturates may also result in a significant decrease in variability as these drugs are known to cross the placental barrier.

Open-glottis pushing

Method of breathing during bearing-down efforts characterized by a strong expiratory grunt or groan."

Leopold maneuvers

Method used to palpate fetus through abdomen."

Leopold's Maneuvers

Methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds. -If head in fundus-> hard, round, movable object is felt. -Buttocks feel soft and have irregular shape and more difficult to move. -Fetus back; smooth hard surface should be felt on one side of abdomen. -Irregular knobs and lumps (hands, feet, elbows and knees felt on opposite side of abdomen.

At 40 weeks' gestation, a woman calls, excited that she is "finally in labor." Which signs and symptoms support that she is not in labor? Select all that apply. Mild discomfort felt in the abdomen and pelvis Contractions that subside with increased activity No significant change in cervical effacement or dilatation A consistent pattern of contractions that increase in frequency and duration Discomfort that begins in the lower back and gradually sweeps around to the lower abdomen like a girdle

Mild discomfort felt in the abdomen and pelvis Discomfort during true labor typically begins in the lower back and gradually sweeps around to the lower abdomen like a girdle. Correct Contractions that subside with increased activity Walking tends to increase contractions during true labor. Correct No significant change in cervical effacement or dilatation The best distinction between true and false labor is that the contractions of true labor cause progressive changes in the cervix. Effacement and dilatation occur with true labor contractions.

The nurse is palpating the uterus of a laboring woman and notes that the fundus is firm, but not rigid, and that the fingertips are able to indent, but not easily. Which strength contraction is does the nurse note? Mild Strong Regular Moderate

Moderate A moderate strength contraction means a firm fundus, which is difficult to indent with fingertips (feels like touching finger to chin).

While assessing the fetal heart rate (FHR) of a client in labor, what does the nurse identify as normal variability of the FHR? Absent variability Minimal variability Moderate variability Marked variability

Moderate variability Rationale Moderate variability is highly predictive of a normal fetal acid-base balance. It indicates that FHR regulation is not significantly affected by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, preexisting neurologic injury, or central nervous system (CNS) depressant medications. Absent or minimal variability is classified as either abnormal or indeterminate. It can result from fetal hypoxemia and metabolic academia. The significance of marked variability is unclear.

The nurse is assisting a client in labor. What breathing pattern must the nurse remind the client to use when the contractions increase in frequency and intensity in the first phase of labor? Slow-paced breathing Modified-paced breathing 3:1 pattern-paced breathing 4:1 pattern-paced breathing

Modified-paced breathing Rationale During the first phase of labor, as contractions increase in frequency and intensity, the client must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the client's normal rate of breathing, but should not exceed twice the resting respiratory rate. Slow-paced breathing is performed at approximately half the normal breathing rate and is initiated when the client can no longer walk or talk through contractions. Patterned-paced breathing is suggested in the second phase of labor. It consists of panting breaths combined with soft blowing breaths at regular intervals. The patterns may vary; the 3:1 pattern is pant, pant, pant, blow and the 4:1 pattern is pant, pant, pant, pant, and blow.

What intervention does the nurse provide during the birthing process to ensure the safety of the mother and the fetus? Provide ongoing feedback to the client and her partner. Encourage the client to experiment with various positions. Monitor the client's emotional and physiologic responses. Continue to provide comfort measures and minimize distractions.

Monitor the client's emotional and physiologic responses. Rationale The nurse should monitor the client's emotional and physiologic responses during the birthing process to ensure the safety of mother and fetus. This helps with effective individual coping related to the birthing process. Providing ongoing feedback to the client and her partner helps decrease anxiety and enhance participation in birthing process. Encouraging the client to experiment with various positions may assist in the downward movement of fetus, but may be uncomfortable for the mother. Providing comfort measures and minimizing distractions may reduce discomfort in the client and help her focus on the birth process.

Which action does the nurse take before administering meperidine hydrochloride (Demerol) to a client to relieve labor pain? Administers 1000 ml normal saline solution Asks the client to use relaxation techniques Asks the client to assume an upright position Monitors maternal vital signs and fetal heart rate

Monitors maternal vital signs and fetal heart rate Rationale Meperidine hydrochloride (Demerol) affects fetal oxygenation, because it decreases maternal heart and respiratory rates along with blood pressure. Therefore, the nurse needs to monitor maternal vital signs and fetal heart rate before administering the medication. The nurse administers 1000 ml normal of saline solution as a preanesthetic fluid bolus to decrease the potential for hypotension. Relaxation techniques alone are not enough in this case, because the pain has already progressed, and should be reduced through pharmacologic measures. The client assumes an upright position after a spinal anesthetic solution has been injected so that it flows downward, and a lower level of anesthesia is obtained for vaginal birth.

A pregnant client is extremely anxious during the labor process. Which condition does the nurse assess in the client that may occur due to anxiety?> Increase in blood flow Rapid progress of labor Decrease in muscle tension More catecholamine secretion

More catecholamine secretion Rationale Excessive anxiety in the client increases catecholamine levels during labor, which increase the stimuli to the brain from the pelvis. This process decreases blood flow and magnifies pain perception. The client becomes more anxious and the effectiveness of uterine contractions decreases, ultimately slowing the progress of labor. A heightened sense of anxiety and fear also increases muscle tension, thereby increasing discomfort.

Late decelerations

Nonreassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency Patterns look similar to early decelerations but begin well after the contraction begins and return to baseline after contraction ends. Interventions: immediately improving placental blood flow and fetal oxygenation

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? Call for help. Insert a Foley catheter. Start oxytocin (Pitocin). Notify the primary health care provider immediately.

Notify the primary health care provider immediately. To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also, if oxytocin is being infused, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately. Although it is always a good idea to have extra help during any unanticipated obstetric event, calling for help is not the most important nursing measure at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section might be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus.

The primary health care provider administers the prescribed spinal anesthesia to a pregnant client for cesarean birth. The nurse notes that the client's systolic blood pressure drops to 100 mm Hg after the administration. On further assessment, the nurse finds a late deceleration in the fetal heart rate. What actions does the nurse take? Select all that apply. Place the client's legs flat on the bed. Notify the primary health care provider. Assist client into a left side-lying position. Continue to monitor maternal blood pressure. Administer oxygen by nonrebreather facemask.

Notify the primary health care provider. Assist client into a left side-lying position. Continue to monitor maternal blood pressure. Administer oxygen by nonrebreather facemask. Rationale A drop in the systolic blood pressure indicates maternal hypotension, which may further cause fetal distress. Therefore, the nurse needs to obtain a prescription for ephedrine or phenylephrine immediately. The nurse assists the client to the left side in order to take pressure off of the major maternal vessels and to optimize the flow of oxygen to the placenta. Continuous monitoring of maternal blood pressure is necessary until the client's condition is stable. The nurse administers the prescribed oxygen by nonrebreather face mask to prevent respiratory distress. The nurse elevates the client's legs to reduce the symptoms of hypotension.

Guidelines for Supporting the Father During Birth:

Orient him to room and unit Inform him on sights/smells he can expect Encourage to leave the room if necessary Respect his or the couple's decision on his involvement Tell him when his presence has been helpful Comfort measures Inform him about progress Prepare him for changes in woman's behavior/appearance Remind him to eat Relieve him of the job of support as necessary Acknowledge the stress he may experience Attempt to modify or eliminate unsettling stimuli

slow paced breathing

Paced breathing technique during which the woman breathes at approximately half her normal rate (6-8 breaths per minute). It is usually the first technique used in early labor when the woman can no longer talk or walk her way through a contraction. half the normal breathing rate - IN-2-3-4/OUT-2-3-4/IN-2-3-4...

pain during 3rd stage of labor

Pain experienced during the third stage of labor, and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor.

What action does the nurse take when using a tocotransducer on a client during preterm labor? Assist the client to lie in a supine position. Palpate to assess the contraction frequency. Secure the device just above the umbilicus. Rely on the device to identify uterine activity

Palpate to assess the contraction frequency. Rationale The fetal monitor of the tocotransducer is designed to assess uterine activity (UA) in full-term pregnancy. Because it is not always sensitive enough to detect preterm UA, the nurse may use palpation as an additional way of assessing contraction frequency and validating monitor tracing. The device confines the client to a bed or a chair. The client is assisted into a semi-Fowler or lateral position for comfort. If a pregnant patient is placed in a supine position, it can cause hypotension. The device is placed over the fundus above the umbilicus for a patient in term labor. However, the fundus may be below the umbilicus in a client with preterm labor. The nurse must rely on the client and use palpation to identify UA, rather than depend on the device.

The nurse should perform which assessment to ensure proper uterine involution after birth? Range of motion Bladder ultrasound Palpating the fundus Level of consciousness

Palpating the fundus Because bleeding is caused by an uncontracted uterus, the fundus must be palpated at regular intervals to assess for firmness, which indicates contraction of the uterine muscle.

When evaluating the Apgar score, which assessments should the nurse make? Select all that apply. Palpation of the radial artery Use of the heart rate monitor Palpation of the carotid artery Palpation of the umbilical cord Auscultation with a stethoscope

Palpation of the umbilical cord Heart rate is determined by palpation of the umbilical cord to ensure accurate measure. Auscultation with a stethoscope Heart rate is determined by auscultation with a stethoscope.

Match the patient with the appropriate type of anesthesia.

Patient who requires a vaginal laceration repair after delivery Pudendal block Patient in labor who would like pain relief and to be awake for the birth Epidural block Patient who has an active skin infection on back and requires an emergency cesarean delivery General anesthesia Patient in labor who would like to have pain relief but still feel contractions and be able to move Combined spinal-epidural anesthesia

A pregnant patient arrives at the intrapartum unit fully dilated and indicates that the baby is on its way. Which information is a priority for nurse to document? Select all that apply. Patient's name. Child's pediatrician. Maternal heart rate. Gestational age of infant. Status of fetal membranes.

Patient's name. The patient's name is an important point to document when birth is imminent in a patient arriving at the intrapartum unit. Maternal heart rate. Maternal vital signs are important information to document when birth is imminent in a patient arriving at the intrapartum unit. Correct Gestational age of infant. Knowledge of anticipated gestational age of the infant is critical in order to prepare for safe delivery when a patient arrives on the intrapartum unit crowning. Correct Status of fetal membranes. The status of the fetal membranes is an important point to document when birth is imminent in a patient arriving at the intrapartum unit.

The nurse has assisted a laboring patient through delivery and is informing her that a postpartum nurse will now care for her. The patient thanks the nurse for all her help and says, "That was a much better experience than I had hoped." Why is it is important that the patient perceive her birth experience as positive? Patients who perceive their birth experience as negative are at higher risk for postpartum depression. Patients who perceive their birth experience as positive are more likely to have a medication-free labor with the next birth. Patients who perceive their birth experience as positive help the nurse get a better performance review. Patients who perceive their birth experience as negative will make inappropriate decisions about future family planning.

Patients who perceive their birth experience as negative are at higher risk for postpartum depression.

Which phase of the contraction cycle likely would be the most painful for the laboring woman? Peak Increment Decrement Effacement

Peak The peak of contraction is when the pressure is the greatest and the associated discomfort is at the maximum point during the contraction.

Stage 2 Interventions

Perform assessments every 5 minutes. Monitor maternal vital signs. Monitor FHR with the use of Doppler ultrasound, a fetoscope, or an electronic fetal monitor. Assess FHR before, during, and after a contraction, keeping in mind that normal FHR is 120 to 160 beats/min. Assess uterine contractions by means of palpation or with the use of a monitor, determining frequency, duration, and intensity. Provide mother with encouragement and praise and provide for rest between contractions. Keep mother and partner informed of progress. Maintain privacy. Provide ice chips and ointment for dry lips. Assist mother into a position that promotes comfort and assists pushing efforts, such as the lithotomy position, semisitting, kneeling, side-lying, or squatting, Monitor mother for signs of approaching birth, such as perineal bulging or appearance of the fetal head. Prepare for birth. After the birth, provide initial newborn care. Assess mother for shivering and provide warmth as needed. Promote parental-neonatal attachment.

Emergency Medical Treatment and Active Labor Act (EMTALA)

Pregnant women who present with contractions or who may be in labor are considered unstable and must be assessed, stabilized, and treat at the hospital where they present regardless of their insurance status or ability to pay.

In which condition does the nurse document the fetal heart rate (FHR) tracing as category III? Prolonged FHR decelerations Presence of a sinusoidal pattern Recurrent variable decelerations Moderate baseline FHR variability

Presence of a sinusoidal pattern Rationale When categorizing the FHR tracing, the presence of a sinusoidal pattern meets the criteria for a category III, or abnormal, tracing. Immediate evaluation and prompt intervention is required when these patterns are identified. Prolonged FHR decelerations greater than or equal to 2 minutes but less than 10 minutes are category II FHR tracings. Recurrent variable decelerations accompanied by minimal or moderate baseline variability are also categorized as a category II FHR tracing. Category II FHR tracings are indeterminate and require continued observation and evaluation. An FHR tracing with moderate baseline FHR variability is categorized as category I, or normal.

Things to consider in creating a Birth Plan

Presence of birth companions Presence of other persons in the room Clothing to be worn Environmental modifications Preferred positions, birth balls, ambulation, shower, whirlpool, food/fluid intake Comfort/relaxation measures Labor and birth medical interventions Care and handling of newborn Cultural and religious requirements

What should be included in the birth plan? Presence of birth companions and the role each will play Presence of other persons such as other clients and students Cultural and religious requirements related to the care of the mother, newborn, and placenta Labor activities such as preferred positions for labor and birth, ambulation, birth balls, showers and whirlpool baths, oral food and fluid intake Labor and birth medical interventions such as pharmacologic pain relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy Care and handling of the newborn immediately after birth such as immediate skin-to-skin contact, cutting of the cord, eye care, and breastfeeding

Presence of birth companions and the role each will play Cultural and religious requirements related to the care of the mother, newborn, and placenta Labor activities such as preferred positions for labor and birth, ambulation, birth balls, showers and whirlpool baths, oral food and fluid intake Labor and birth medical interventions such as pharmacologic pain relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy Care and handling of the newborn immediately after birth such as immediate skin-to-skin contact, cutting of the cord, eye care, and breastfeeding Rationale The birth plan should include the presence of birth companions and the role each will play; the presence of other persons such as students or male attendants (not other clients); cultural and religious requirements related to the care of the mother, newborn, and placenta; labor activities such as preferred positions for labor and birth, ambulation, birth balls, showers and whirlpool baths, and oral food and fluid intake; labor and birth medical interventions such as pharmacologic pain relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy; and care and handling of the newborn immediately after birth, such as immediate skin-to-skin contact, cutting of the cord, eye care, and breastfeeding.

A patient arrives at the Labor and Delivery unit with steady contractions and is 5 cm dilated. On assessment, the fetal heart rate is 200 beats per minute, and it is determined that a cesarean delivery should be performed. Which anesthesia method does the nurse anticipate? Pudendal block General anesthesia Subarachnoid (spinal) block Local infiltration anesthesia

Subarachnoid (spinal) block The nurse would anticipate a subarachnoid block (SAB), because it is recommended when a quick cesarean birth is necessary and an epidural catheter is not in place.

A client is prescribed spinal anesthesia in preparation for a cesarean birth. The primary health care provider instructs the nurse to administer a preanesthetic fluid bolus. What is the purpose of this prescription? Prevent maternal hypotension Potentiate effect of anesthesia Maintain fluid balance Prevent neonatal hypoglycemia

Prevent maternal hypotension Rationale Spinal anesthesia may cause sympathetic blockade and increase the client's risk for hypotension. Therefore, the primary health care provider prescribes a preanesthetic fluid bolus 15 to 30 minutes before administering anesthesia. This will prevent hypotension in the client. There is no need to potentiate the effect of anesthesia, because the prescribed dose has optimum effect on the client. The nurse can maintain fluid balance by providing enough fluids to the client. There is a risk for neonatal hypoglycemia if the fluid bolus contains dextrose.

A 40-year-old gravida 3, para 2 has received an epidural anesthetic for pain management during labor. Her cervix is 8 cm dilated and 100% effaced. She rates her pain as 8 on a scale of 0 to 10. She is able to talk through her contractions without grimacing and is dozing between contractions. She asks the nurse, "Why isn't my epidural working? I didn't feel anything with my other babies." Which of the following explanations would be appropriate for the nurse to relay to the patient? Previous birth experiences may affect a patient's perception and expectations of the current labor process. Because of advanced age, the patient probably does not tolerate discomfort as well as she used to. The patient is probably fatigued and is not coping well with pain. The laboring patient is more dependent and wants to keep the nurse in the room.

Previous birth experiences may affect a patient's perception and expectations of the current labor process.

With regard to primary and secondary powers, the maternity nurse should understand that: Primary powers are responsible for effacement and dilation of the cervix. Effacement generally is well ahead of dilation in women giving birth for the first time; they are more together in subsequent pregnancies. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

Primary powers are responsible for effacement and dilation of the cervix. The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement is generally well ahead of dilation in first-timers; the two are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

External Cephalic Version (ECV)

Procedure involving external manipulation of the maternal abdomen to change the presentation of the fetus from breech to cephalic. Typically done at 36-37 weeks. Beta stimulants to relax the uterus (Terbutaline) Most likely successful for multiparous women with adequate amount of amniotic fluid Uncomfortable or painful Risky

Effacement

Process of shortening and thinning of the cervix during the first stage of labor. Progress is expressed in percentages from 0% to 100%

The nurse should tell a primigravida that the definitive sign indicating that labor has begun is what? Progressive uterine contractions with cervical change. Lightening. Rupture of membranes. Passage of the mucus plug (operculum).

Progressive uterine contractions with cervical change. Rationale Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucus plug is a premonitory sign indicating that the onset of labor is getting closer

The nurse is assessing a fetal heart rate and notes a decrease in heart rate to 100 bpm at the peak of contraction that does not resolve for 3 minutes. How does the nurse describe this pattern? Accelerations Tachycardia Early decelerations Prolonged decelerations

Prolonged decelerations Prolonged decelerations begin at or after the peak contraction. The return to baseline fetal heart rate usually occurs after the contraction is over.

Nurses should be aware of the difference that experience can make in labor pain, such as: Sensory pain for nulliparous women often is greater than for multiparous women during early labor. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. Women with a history of substance abuse experience more pain during labor. Multiparous women have more fatigue from labor and therefore experience more pain.

Sensory pain for nulliparous women often is greater than for multiparous women during early labor. Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Stage 3

Separation of placenta Expulsion of placenta Mother is relieved after birth of newborn; mother usually very tired. Interventions- Schultze mechanism center portion of placenta separates first, its shiny fetal surface emerges from vagina. Duncan mechanism margin of placenta separates and dull red, rough Maternal surface emerges from vagina first. After expulsion of placenta- uterine fundus remains firm and located 2 finger breadths below the umbilicus

Second-Stage Breathing

Several variations of breathing can be used in the pushing stage of labor, and the woman may grunt, groan, sigh, or moan as she pushes. Prolonged breath holding while pushing with a closed glottis may result in a decrease in cardiac output. If breath holding while pushing is used, the open glottis method or limiting breath holding to less than 6 to 8 seconds should be done.

Which type of fetal presentation results most often in caesarean section? Cephalic Vertex Shoulder Full Breech

Shoulder The shoulder presentation is a transverse lie and accounts for less than 1% of births, usually premature. A cesarean birth is necessary.

A patient is experiencing a moderate level of pain and discomfort during active labor contractions and requests to remain lying down. Which position should the nurse encourage the patient to assume? Standing Side-lying Sitting upright Kneeling, leaning forward with support

Side-lying This position offers a break from more tiring positions. Use pillows for support and to prevent pressure.

Which are advantages of having the patient in the side-lying position during active labor? Select all that apply. Side-lying is a restful position. Side-lying promotes blood flow. Left side-lying reduces supine hypotension. Side-lying adds gravity to force of contractions. Side-lying reduces back pain because the fetus falls forward.

Side-lying is a restful position. Side-lying position offers a break from more tiring positions. Side-lying promotes blood flow. Side-lying position promotes placental blood flow by relieving pressure on involved vessels. Left side-lying reduces supine hypotension. Left side-lying position reduces supine hypotension by relieving pressure from the inferior vena cava.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? The healthy newborn should be taken to the nursery for a complete assessment. After drying, the infant should be given to the mother wrapped in a receiving blanket. Skin-to-skin contact of mother and baby should be encouraged. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

Skin-to-skin contact of mother and baby should be encouraged. The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. Although complete assessment in the nursery is the practice in many facilities, it is neither evidence-based nor supportive of family-centered care. Handing the mother the blanket-wrapped baby is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed on the mother skin to skin. The father or support person is likely also anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin with the mother and breastfeeding has been initiated.

Which breathing techniques can be used by a pregnant client in labor to control pain during contractions? Select all that apply. Slow-paced breathing Holding her breath during contractions Panting breaths Modified-paced breathing Random-paced breathing

Slow-paced breathing Panting breaths Modified-paced breathing Rationale The nurse encourages the client to perform slow-paced breathing when the client can no longer walk or talk through contractions. This aids in relaxation and provides optimum oxygenation. The client takes panting breaths to overcome the urge to push when the cervix is not fully prepared. Modified-paced breathing blocks more painful stimuli than the simpler slow-paced breathing pattern. Random-paced breathing would not be recommended to help a client control pain during contractions. Instead, patterned-paced breathing, or pant-blow breathing, consists of panting breaths combined with soft blowing breaths at regular intervals; this pattern is thought to be most helpful during the first stage of labor, when the cervix is dilating. Holding the breath is not recommended, because it does not maintain adequate oxygen flow to the fetus.

Causes of fetal bradycardia

Some type of fetal cardiac problem such as structural defects involving the pacemaker or conduction system or fetal heart failure, viral infections, maternal hypoglycemia, and maternal hypothermia

The anesthesia care provider accidentally causes dural puncture while administering an epidural block to a pregnant client in labor. On assessment, the primary health care provider prescribes an autologous epidural blood patch for the client. Which condition in the client indicates a need for this order? Fetal hypoxia Hypotension Leakage of fluid Spinal headache

Spinal headache Rationale The dural puncture may cause postdural puncture headache (PDPH), or spinal headache. The use of an autologous epidural blood patch helps constrict the cerebral blood vessels and relieve the spinal headache. Fetal hypoxia is a side effect of opioids and occurs due to a decrease in maternal heart and respiratory rates and blood pressure. Hypotension may occur as a side effect of spinal anesthesia. The leakage of cerebrospinal fluid may be a side effect of the blood patch.

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? Semirecumbent Sitting Squatting Side-lying

Squatting Rationale Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. A semirecumbent position does not assist in increasing the size of the pelvic outlet. Although sitting may assist with fetal descent, this position does not increase the size of the pelvic outlet. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? Semirecumbent Sitting Squatting Side-lying

Squatting Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. Sitting may assist with fetal descent, but like a semirecumbent or side-lying position, it does not increase the size of the pelvic outlet.

china

Stoic response to pain; father not usually present; side-lying position preferred for labor and birth process because this position is thought to reduce infant trauma

The nurse is providing care for a client with twins during labor. The nurse instructs the client to avoid lying flat on the back. Which condition does the nurse aim to prevent in the client during labor? Valsalva maneuver Supine hypotension Respiratory alkalosis Painful uterine contractions

Supine hypotension Rationale Supine hypotension may be seen in the pregnant client when the ascending vena cava and descending aorta are compressed. The client is more at risk for hypotension in the case of multifetal pregnancy due to a drop in hydrostatic pressure when lying supine. Valsalva maneuver refers to the client holding her breath and tightening the abdominal muscles to help with pushing. Respiratory alkalosis may occur in a pregnant client due to hyperventilation and not by lying flat on the back. Epidural analgesia is often prescribed to decrease pain experienced during uterine contractions.

Pain impulses during the first stage of labor are transmitted via the _____ to _____ spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves.

T1 to T12

What does the nurse teach a couple expecting their first child about the use of therapeutic touch (TT) to relieve pain during labor? TT uses the concept of energy fields within the body. Back massage is found to be beneficial in advanced labor. TT involves the application of pressure to the patient's hips. Prana are thought to be in excess in people who are in pain.

TT uses the concept of energy fields within the body. Rationale Therapeutic touch (TT) uses the concept of energy fields within the body, called prana. Specially trained persons lay hands on to redirect energy fields associated with pain. According to this concept, prana are thought to be deficient in some people who are in pain. Counterpressure is steady pressure applied by a support person to both hips to cope with the sensation of internal pressure. Hand and foot massage is found to be especially relaxing in advanced labor when hyperesthesia limits the patient's tolerance for touch on other parts of the body.

birth ball

The __ __ can encourage pelvic mobility and pelvic and perineal relaxation when the woman sits on the firm yet pliable ball and rocks in rhythmic movements The birth ball should be large enough that, when the woman sits, her knees are bent at a 90 degree angle and her feet are flat on the floor and approximately 2 feet apart.

point of maximal intensity (PMI)

The __ of FHR is the location on the maternal abdomen in which the FHR is heard the loudest - back

side-lying (lateral)

The __ position is preferred because it promotes optimal uteroplacental and renal blood flow and increases fetal oxygen saturation.

2nd stage of labor

The __ stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The median duration of second-stage labor is 50-60 minutes in nulliparous women and 20-30 minutes in multiparous women.

The nurse is caring for a client who had a normal vaginal birth. The client is concerned about the shape of the infant's head. What does the nurse tell the client? Select all that apply. The bones of the skull continue to grow after birth. The shape of the head undergoes molding during labor. The head assumes its normal shape within a month. The skull bones of an infant are generally firmly united. The sutures and fontanels make the skull flexible.

The bones of the skull continue to grow after birth. The shape of the head undergoes molding during labor. The sutures and fontanels make the skull flexible. Rationale The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant.

The nurse is caring for a client who had a normal vaginal birth. The client is concerned about the shape of the infant's head. What does the nurse tell the client? Select all that apply. The bones of the skull continue to grow after birth. The shape of the head undergoes molding during labor. The head assumes its normal shape within a month. The skull bones of an infant are generally firmly united. The sutures and fontanels make the skull flexible.

The bones of the skull continue to grow after birth. The shape of the head undergoes molding during labor. The sutures and fontanels make the skull flexible. Rationale The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant.

The nurse knows that the second stage of labor, the descent phase, has begun when: The amniotic membranes rupture. The cervix cannot be felt during a vaginal examination. The woman experiences a strong urge to bear down. The presenting part is below the ischial spines

The cervix cannot be felt during a vaginal examination. The second stage of labor begins with full cervical dilation. During the active pushing phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as at 5 cm dilation.

Which fetal attitude is seen in general flexion? Select all that apply. The chin is flexed on the chest. The legs are flexed at the knees. The fetal head is extended. The thighs are flexed on the abdomen. The arms are crossed over the thorax.

The chin is flexed on the chest. The legs are flexed at the knees. The thighs are flexed on the abdomen. The arms are crossed over the thorax. Rationale Attitude or posture refers to the relation of the fetal body parts to one another. The attitude of general flexion is seen in most pregnancies. The chin is flexed on the chest, as the back of the fetus is rounded. As a result, the legs are flexed at the knees, and the thighs are flexed on the abdomen. The arms are crossed over the thorax, and the umbilical cord lies between the arms and legs. An extended fetal head indicates a deviation from the normal attitude that may cause difficulties during childbirth.

A pregnant woman who is in the first stage of labor has a body weight of 73 kg. While reviewing the medical reports, the nurse finds that the client's prepregnant body weight was 53 kg. What does the nurse interpret about the client? The client has an increased risk of prolonged labor. The client has an increased risk of caesarean delivery. The client is likely to require oxytocin to induce labor. The client is likely to have stronger uterine contractions during labor.

The client has an increased risk of caesarean delivery. Rationale The client has gained 20 kg over the 9 months of pregnancy. Weight gain of more than 16 kg during pregnancy indicates that the client is at high risk of cephalopelvic disproportion, and may require a caesarean delivery. Prolonged labor may be caused by breech presentation or occiput posterior position of the fetus. Inadequate uterine contractions or weak uterine contractions indicate a need for oxytocin administration during delivery. The strength of uterine contractions is not dependent on weight gain during pregnancy.

The nurse is caring for a Chinese client who is in labor. Which behavior by the client is inconsistent with common Chinese cultural practices? The client is extremely anxious during the labor. The client opted for natural methods of delivery. The client prefers to be in the side-lying position during labor. The client does not want the father to be present during labor.

The client is extremely anxious during the labor. Rationale Chinese women are often stoic during labor and are typically able to withstand higher thresholds of pain. Extreme anxiety during labor is not a characteristic behavior of Chinese women. Indian and Japanese women may be more likely to opt for natural delivery than a Chinese woman. Chinese women often prefer being in side-lying position during labor, so this would not be considered an unusual behavior. In Chinese culture, the father is usually not present during labor, so this would not be considered an unusual finding for this client.

The nurse is assisting a client during the second phase of labor. Which behavior from the client signifies the active pushing stage of the second phase of labor? The client may scream or swear. The client feels fatigued and sleepy. The client is inattentive to the nurse's instructions. The client is quiet, and is anxious about the progression of labor.

The client is inattentive to the nurse's instructions. Rationale There are two phases during the second stage of labor, the latent and the active. The active stage is the pushing stage of labor, in which the client experiences severe pain and tries to push the fetus with all her effort. The client is inattentive to the nurse and directs all her concentration on childbirth. During the active phase of vocalization, the client may scream or swear, because the pain is severe.The client feels fatigued and sleepy during the latent phase, not during the active phase. During the latent phase, the client remains quiet and is concerned with the progress of the labor.

A pregnant client who is full term has a cervical dilatation of 2 cm. The nurse asks the client to get admitted the next day, but after talking to the client, the nurse allows the client to be admitted the same day. What are the reasons for admitting the client in the latent stage of labor? Select all that apply. The client lives far away from the birth center. The client has occasional strong uterine contractions. The client had rapid labors in the past two deliveries. The client is a single mother and has no other family. The client is stressed and anxious regarding the birthing process.

The client lives far away from the birth center. The client had rapid labors in the past two deliveries. The client is a single mother and has no other family. Rationale Pregnant women who are in labor are generally not admitted to the birth center until the cervix is dilated to 3 cm. In this case, the client's cervical dilatation is only 2 cm but the client may be admitted early if the client lives far from the birth center, making it difficult for the client to travel back when her labor progresses. Early admission may be particularly important if a client has had rapid births in the past because it's likely she will have another rapid labor this time. Early admission may also be allowed if the client lacks family support, such as in the case of a single mother. This client is in the early phase of labor and, therefore, is expected to have occasional strong uterine contractions. This is not a criterion for admitting the client. Stress and anxiety regarding the birthing process is common in clients who are in labor. This is not a criterion for early admission to the birthing center.

What cultural beliefs must the nurse keep in mind when caring for a Chinese client in labor? The client may become vocal late in labor. The client may not exhibit reactions to pain. The client may use remedies made from plants. The client may refuse pain medication when it is offered the first time. The client may prefer acupuncture for pain relief.

The client may not exhibit reactions to pain. The client may refuse pain medication when it is offered the first time. The client may prefer acupuncture for pain relief. Rationale The Chinese client may not exhibit reactions to pain, although exhibiting pain reactions during childbirth is acceptable. The nurse must offer pain interventions more than once, because the client may consider it impolite to accept something when it is first offered. The Chinese client generally prefers to use acupuncture for pain relief. Native-American clients may use medications or remedies made from indigenous plants. Hispanic clients may become vocal and request for pain relief late in labor.

What behavior does the nurse expect in a client who is in the transition phase during the first stage of labor? The client remains calm and silent. The client doubts her ability to control pain. The client vomits. The client's attention is directed inward.

The client vomits. Rationale A client in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The client may hyperventilate, resulting in nausea and vomiting. The client may remain calm and silent in the latent phase of uterine contractions, because the urge to bear down is not too strong in this phase. During the active stage of labor, the client may become doubtful of her ability to control pain. The client's attention is directed inward in the active phase of the first stage of labor.

The nurse is assisting a client during the active phase of the second stage of labor. The nurse finds that the client has a sudden, significant increase in dark red bloody show. What does the nurse infer from this observation? The discharge indicates that the fetal head is about to deliver. The discharge indicates high maternal blood pressure. The discharge indicates a potential complication of labor. The discharge indicates maternal and fetal infection.

The discharge indicates that the fetal head is about to deliver. Rationale In a normal vaginal delivery, the fetus head is born first. The passage for childbirth gets stretched as the fetal head descends down, resulting in increased dark red bloody show. Therefore, a significant increase in dark red bloody show indicates the birth of the fetal head. The dark red colored bleeding does not indicate high blood pressure. A significant increase in bleeding is a potential complication in the fourth stage of labor. The seepage of amniotic fluid may indicate that the amniotic sac had broken, which may lead to maternal and fetal infection.

Concerning the third stage of labor, what should nurses be aware of? The placenta eventually detaches itself from a flaccid uterus The duration of the third stage may be as short as 3 to 5 minutes It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface The major risk for women during the third stage is a rapid heart rate

The duration of the third stage may be as short as 3 to 5 minutes Rationale The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

Concerning the third stage of labor, nurses should be aware that: The placenta eventually detaches itself from a flaccid uterus. The duration of the third stage may be as short as 3 to 5 minutes. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. The major risk for women during the third stage is a rapid heart rate.

The duration of the third stage may be as short as 3 to 5 minutes. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage; the risk of hemorrhage increases as the length of the third stage increases.

Concerning the third stage of labor, nurses should be aware of that? The placenta eventually detaches itself from a flaccid uterus The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface The major risk for women during the third stage is a rapid heart rate

The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered Rationale The duration of the third stage of labor may be short. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware of what? The woman's blood pressure increases during contractions and falls back to prelabor baseline between contractions Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia Having the woman point her toes reduces leg cramps The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation

The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation Rationale Physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during the second stage of labor because it may lead to a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. Having the woman point her toes reduces leg cramps. The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation

The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second-stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

When assessing uterine activity, nurses should be aware of what? The examiner's hand should be placed on the fundus before, during, and after contractions The frequency and duration of contractions are measured in seconds for consistency Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together The resting tone between contractions is described as either placid or turbulent

The examiner's hand should be placed on the fundus before, during, and after contractions Rationale The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: The examiner's hand should be placed over the fundus before, during, and after contractions. The frequency and duration of contractions are measured in seconds for consistency. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. The resting tone between contractions is described as either placid or turbulent.

The examiner's hand should be placed over the fundus before, during, and after contractions. The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

During the vaginal examination of a client, the nurse notes that the fetus is in an oblique lie. What does this indicate? The fetus cannot be born by vaginal birth. The long axis of the mother and fetus are parallel. The presentation is either cephalic or breech. The fetal lie will undergo change during labor.

The fetal lie will undergo change during labor. Rationale If the fetus is in an oblique lie, it usually converts to a longitudinal or transverse lie during labor. In an oblique lie the long axis of the fetus lies at an angle to the long axis of the mother. Fetal lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Vaginal birth cannot occur when the fetus stays in a transverse lie. In the longitudinal lie, the long axis of the fetus is parallel with the long axis of the mother. Longitudinal lies are either cephalic or breech presentations, depending on the fetal structure that first enters the mother's pelvis.

The nurse is performing Leopold's maneuver in a client who is in the first stage of labor. What information does the nurse obtain while performing these maneuvers? Select all that apply. The fetal heart rate The fetal part in the fundus The tone of the uterus The presenting part of the fetus The descent of the fetus into the pelvis

The fetal part in the fundus The presenting part of the fetus The descent of the fetus into the pelvis Rationale Leopold maneuvers, or abdominal palpation, during first stage of labor help determine the fetal part present in the fundus, which indicates the fetal lie. The presenting part of the fetus would help determine if the patient should undergo vaginal birth or requires a cesarean delivery. The position and location of the fetal back helps to determine the descent of the fetus into the pelvis, which indicates the approximate time required for vaginal delivery. The fetal heart rate can only be auscultated using a Doppler ultrasound. However, using abdominal palpation, the point of maximum intensity of the fetal heart rate can be determined. The nurse may not assess the tone of the fundus during the first stage of labor. The tone of the fundus is assessed after the delivery of the child to determine the risk of postpartum hemorrhage.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? The fetal presenting part is 1 cm above the ischial spines. Effacement is 4 cm from completion. Dilation is 50% completed. The fetus has achieved passage through the ischial spines.

The fetal presenting part is 1 cm above the ischial spines. Rationale Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as

Which physiological event is associated with lightening? The fetus assumes a position lower in the pelvis. The cervix begins to soften, dilate, and efface slightly. Fetal pressure causes congestion of the vaginal mucosa. The extra interstitial fluid that accumulates during pregnancy is excreted.

The fetus assumes a position lower in the pelvis. Lightening ("dropping") occurs as the fetus descends toward the pelvic inlet

The nurse is reviewing the reports of a client who is 36 weeks pregnant. What does the nurse conclude after reviewing the reports? The client may require a cesarean birth. The fetus has an infection, but the amniotic sac is intact. The fetus has an infection, and the amniotic sac is ruptured. The client is at risk of impaired urinary elimination.

The fetus has an infection, and the amniotic sac is ruptured. Rationale The ECV is performed to align the fetal position to a cephalic lie. Cephalic lie is a normal alignment. A cotton-tipped applicator impregnated with Nitrazine dye is used to determine the pH of the vaginal fluid. A blue-green nitrazine test indicates a pH of 6.5, which in turn indicates the presence of amniotic fluid in the vagina. Placentitis refers to inflammation of the placenta due to infection. Therefore, based on the given data, the fetus has an infection, and the amniotic sac is ruptured. Because the fetal alignment is in a cephalic lie, the client is most likely to have a vaginal birth. There would be no seepage of fluids if the amniotic sac were intact. The client with a palpable bladder is at risk of impaired urinary elimination.

After performing the Leopold's maneuver on a client at 38 weeks of pregnancy, the nurse concludes that the client will require external cephalic version for having a vaginal delivery. What was the finding during assessment? The client had a short pelvic outlet. The fetus is in the breech presentation. The fetus had not descended in the pelvis. The client has weak uterine contractions.

The fetus is in the breech presentation. Rationale External cephalic version is an ultrasound-guided, hands-on technique that is used to externally manipulate the fetus into a cephalic lie. This technique is indicated when the fetus has a noncephalic presentation such as breech presentation. If the client has a short pelvic outlet, the client must usually undergo a caesarean delivery. External cephalic version cannot be done if the fetus has not descended in the pelvis. The client is not in labor, so the client will have weak uterine contractions.

The first stage of labor begins with the onset of _______________________________ and ends with complete cervical _______________________________ and _______________________________. A blood-tinged mucous discharge (bloody show) from the vagina usually indicates the passage of the _______________________________."

The first stage of labor begins with the onset of uterine contractions and ends with complete cervical effacement and dilation. A blood-tinged mucous discharge (bloody show) from the vagina usually indicates the passage of the mucous plug."

The nurse will be using a Monica AN24 device to monitor the fetal heart rate (FHR) and uterine activity (UA) of a client in labor. What is the nurse mindful of while using the device? Select all that apply. The monitor uses five electrodes placed on the abdomen. The device may not detect the exact frequency of UA. The patient may move up to 25 feet away from the device. The device eliminates the need for abdominal belts. The device is approved for clients at 36 weeks gestation or more.

The monitor uses five electrodes placed on the abdomen. The device eliminates the need for abdominal belts. The device is approved for clients at 36 weeks gestation or more. Rationale The Monica AN24 device is used to monitor the electrocardiogram from both the maternal and fetal hearts and the electromyogram from the uterine muscles. The monitor uses five electrodes placed on the client's abdomen. The device eliminates the need for abdominal belts and frequent readjustments, because it uses Bluetooth technology. The device is approved only for clients who have completed 36 weeks of gestation or more. The device detects the exact frequency, occurrence of peak, and duration of contractions. The traditional tocotransducer may be unable to detect the exact frequency and duration of UA if the client is obese. The device allows the client to move up to 50 feet away from the interface device without losing the signal.

The nurse is caring for a nulliparous client in labor. How is the experience for a nulliparous client different from that of a multiparous client? The nulliparous client experiences less sensory pain during early labor. The nulliparous client experiences greater sensory pain in the second stage of labor. The nulliparous client experiences greater fatigue due to longer duration of labor. The nulliparous client experiences greater affective pain in the second stage of labor.

The nulliparous client experiences greater fatigue due to longer duration of labor. Rationale Parity influences the perception of labor pain. The nulliparous client often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous client is greater in the first stage as compared to a multiparous client. It decreases for both clients during the second stage of labor. During the second stage of labor, the multiparous client may experience greater sensory pain than the nulliparous client. This is because tissues of the multiparous client are more supple and increase the speed of fetal descent, thereby intensifying the pain.

The nurse is caring for a nulliparous client in labor. How is the experience for a nulliparous client different from that of a multiparous client? The nulliparous client experiences less sensory pain during early labor. The nulliparous client experiences greater sensory pain in the second stage of labor. The nulliparous client experiences greater fatigue due to longer duration of labor. The nulliparous client experiences greater affective pain in the second stage of labor.

The nulliparous client experiences greater fatigue due to longer duration of labor. Rationale Parity influences the perception of labor pain. The nulliparous client often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous client is greater in the first stage as compared to a multiparous client. It decreases for both clients during the second stage of labor. During the second stage of labor, the multiparous client may experience greater sensory pain than the nulliparous client. This is because tissues of the multiparous client are more supple and increase the speed of fetal descent, thereby intensifying the pain.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes what? The placenta has separated A cervical tear occurred during the birth The woman is beginning to hemorrhage Clots have formed in the upper uterine segment

The placenta has separated Rationale Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes that: The placenta has separated. A cervical tear occurred during the birth. The woman is beginning to hemorrhage. Clots have formed in the upper uterine segment.

The placenta has separated. Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Which of the following would be included in a birth plan for an expectant mother? Tracking of the onset of progressive, regular contractions The presence of birth companions such as the partner Preferred position for labor and for birth Medical interventions Discussion of any fears about labor

The presence of birth companions such as the partner Preferred position for labor and for birth Medical interventions Rationale The birth plan should include the woman's or couple's preferences related to presence of birth companions such as the partner, preferred position for labor and birth, and medical interventions. The birth plan does not include the tracking of the onset of progressive, regular contractions or discussion of any fears about labor.

doula

The primary role of the __ is to focus on the laboring woman and to provide physical and emotional support by using soft, reassuring words of praise and encouragement; touching; stroking; and hugging. Also administers comfort measures to reduce pain and enhance relaxation and coping, walks with the woman, helps her change position, and coaches her bearing-down efforts. Advocate for the woman's right to participate actively in managing her labor Supports partner __ support is associated with decreased use of analgesia, decreased incidence of operative birth, increased incidence of spontaneous vaginal birth, and increased maternal satisfaction with the childbirth experience

Which factors play an important role in a pregnant client's satisfaction with the labor and birth experience? The quality of care provided The ability to stay in control of labor The amount of labor pain Fulfilment of the expectations of childbirth Participation in decisionmaking regarding labor

The quality of care provided The ability to stay in control of labor Fulfilment of the expectations of childbirth Participation in decisionmaking regarding labor Rationale The quality of care provided and the prompt resolution of all concerns and queries relieve the client's anxiety, thereby contributing to the client's satisfaction with the labor and birth experience. The ability to stay in control of labor with the use of different pain-relieving measures is also one of the determining factors. The client has certain expectations of childbirth, such as family support, caregiving, and hospital environment, which need to be fulfilled. Participating in the decisionmaking process regarding labor and the use of pharmacologic or nonpharmacologic measures increases the client's confidence. It is not the amount of labor pain but rather how well the woman feels she coped with the pain that determines whether she feels satisfied.

advantages of epidural block

The woman remains alert and is more comfortable and able to participate. • Good relaxation is achieved. • Airway reflexes remain intact. • Only partial motor paralysis develops. • Gastric emptying is not delayed. • Blood loss is not excessive. fetal complications rare woman can pusjh and even walk

The second stage of labor is the stage in which the _______________________________. It begins with full cervical _______________________________ and complete _______________________________. It ends with the ___________ ____________________. This stage is divided into the _______________________________ phase, a period of rest and calm (laboring down), and the phase of _______________________________ (descent). The only certain objective sign that the second stage has begun is the inability to feel the _______________________________ during a vaginal examination."

The second stage of labor is the stage in which the infant is born. It begins with full cervical dilation and complete effacement. It ends with the baby's birth. This stage is divided into the latent phase, a period of rest and calm (laboring down), and the phase of active pushing (descent). The only certain objective sign that the second stage has begun is the inability to feel the cervix during a vaginal examination.

Intensity

The strength of a contraction at its peak

resting tone

The tension in the uterine muscle between contractions; relaxation of the uterus

analgesia

The term refers to the alleviation of the sensation of pain or the raising of the threshold for pain perception *without loss of consciousness.

The third stage of labor lasts from the _____________ until the______________________________. Detachment of the placenta from the wall of the uterus or separation is indicated by a firmly contracting __________ _____________________, change in the shape of the uterus from _______________________________ to ___________ ____________________, a sudden _______________________________ from the introitus, apparent _______________ ________________, and the finding of _______________________________ or of _______________________________ at the introitus."

The third stage of labor lasts from the Birth of the baby until the placenta is expelled. Detachment of the placenta from the wall of the uterus or separation is indicated by a firmly contracting fundus, change in the shape of the uterus from discoid to globular ovoid, a sudden gush of dark blood from the introitus, apparent lengthening of umbilical cord, and the finding of vaginal fullness or of fetal membranes at the introitus.

epidural anesthesia

The use of __ __ often increases the length of the second stage of labor becuase the epidural blocks or reduces the woman's urge to bear down and limits her ability to attain an upright position to push

Breathing to Prevent Pushing

The woman blows repeatedly, using short puffs, when the urge to push is strong.

The nurse knows that what occurs in the second stage of labor, the descent phase? The amniotic membranes rupture. The cervix cannot be felt during a vaginal examination. The woman experiences a strong urge to bear down. The presenting part is below the ischial spines.

The woman experiences a strong urge to bear down. Rationale During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

Valsalva Maneuver

The woman is coached to hold her breath, closing her glottis, and to push while the nurse or partner counts to 10. This may trigger the __ __, which occurs when the woman closes her glottis, which increases intrathoracic pressure and cardiovascular pressure. This reduces cardiac output and decreases perfusion of the uterus and the placenta. Fetal hypoxia, acidosis, increased risk for pelvic floor damage, perineal trauma*** Monitor the woman's breathing so she does not hold her breath for more than 6-8seconds

The charge nurse instructed a group of student nurses about monitoring of uterine activity during labor. Which statement by the student nurse is accurate regarding the calculation of Montevideo units? They can be calculated by using a spiral electrode monitoring device. They can be calculated by using a tocotransducer monitoring system. They can be calculated by utilizing an ultrasound transducer machine. They can be calculated with an intrauterine pressure catheter (IUPC).

They can be calculated with an intrauterine pressure catheter (IUPC). Rationale Montevideo units can only be calculated using the internal monitoring of UA. An intrauterine pressure catheter (IUPC) monitors UA internally. Therefore, Montevideo units can only be calculated using the IUPC. Spiral electrode monitoring is used for assessing the fetal heart rate (FHR), not UA internally. The tocotransducer monitoring system is used to monitor the UA externally. An ultrasound transducer is also used to monitor the FHR externally.

External Fetal Monitoring

This noninvasive mode of monitoring is conducted with the use of a tocotransducer and Doppler ultrasonic transducer. After the Leopold maneuvers are used to determine the side on which the fetal back is located, the ultrasound transducer is placed over this area, then fastened with a belt. The tocotransducer is placed over the fundus of the uterus, where contractions feel the strongest, and also fastened with a belt. Client is allowed to assume a comfortable position, helping prevent vena cava compression.

A nurse assisting in a vaginal birth is asked by the health care provider to wipe expelled maternal feces posteriorly. Which is the main reason for this nursing action? To avoid aspiration of secretions To avoid contaminating the vulva To avoid maternal embarrassment To avoid contamination of the placenta

To avoid contaminating the vulva Any feces expelled are wiped posteriorly to avoid contaminating the vulva.

During the labor process, the primary health care provider instructs the client to maintain a side-lying position before birth. What is the reason behind this instruction? To keep the perineum free of microbes To decrease tension on the perineum To decrease blood loss during labor To decrease postpartum pain

To decrease tension on the perineum Rationale An episiotomy is an incision made in the perineum to enlarge the vaginal outlet. The primary health care provider instructs the client to remain in a side-lying position to decrease the tension on the perineum. This allows the perineum to stretch wide and decreases the necessity for an episiotomy. Blood loss during labor is decreased if the perineum remains intact. A side-lying position does not keep the perineum free of microorganisms; instead the position helps the perineum to stretch for childbirth. Side-lying positions do not decrease blood loss during labor. If the perineum remains intact, the client has less postpartum pain.

While assessing the fundus of a postpartum client, the nurse places both hands, one over the other, on the client's abdomen and applies a downward pressure toward the vagina. What are the rationales behind this intervention? Select all that apply. To assess laceration repair for redness To help the client to void spontaneously To determine whether the fundus is firm To assist the client in expelling clots To assess for the presence of hemorrhoids

To determine whether the fundus is firm To assist the client in expelling clots Rationale During the fourth stage of labor, the nurse must assess parameters such as blood pressure, temperature, and tone of the fundus. The tone of the fundus is assessed to determine if the client is at risk of having a postpartum hemorrhage. Massaging the fundus also helps to expel retained clots from the vagina. Redness or edema is observed while caring for lacerations; however, applying pressure toward the vagina does not aid in repairing the lacerations. The nurse helps the client to void spontaneously to help the client urinate. The perineum is assessed for the presence of hemorrhoids, but applying downward pressure toward the vagina would not be helpful in assessing hemorrhoids.

The nurse says, "You are doing so well; do it again" to a client during the second stage of labor. Why did the nurse say this? To promote comfort and minimize distractions To promote bearing-down efforts in the client To encourage the client to feel confident To promote adequate oxygen levels in the fetus

To encourage the client to feel confident Rationale During the second stage of labor, the client experiences severe pain, fear, anxiety, and confusion. The client might scream during the active pushing stage. Therefore, nurse encourages the client to feel confident in her body. The nurse dims the lights during labor and speaks quietly in order to comfort the client and to minimize distractions. Once the client gains confidence, the bearing-down effort improves. Adequate oxygen levels in the maternal blood can be maintained by asking the client to take rapid breaths.

panting breaths

To ensure the slow birth of the fetal head, encourage the woman to control the urge to bear down by coaching her to take __ __ or exhale slowly through pursed lips as the baby's head crowns

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. What should the nurse's immediate response be? To encourage the woman to breathe more slowly. To help the woman breathe into a paper bag. To turn the woman on her side. To administer a sedative.

To help the woman breathe into a paper bag. Rationale The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Telling her to breathe more slowly does not ensure a change in respirations. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression because this woman, being in the transition phase, is near the birth process. The side-lying position is appropriate for supine hypotension.

While caring for a client in labor, the nurse regularly assesses the client's vital signs and fetal heart tones. Why is it important for the nurse to share this information with the client as the labor progresses? To provide support and comfort measures To educate the client about labor pain To relieve the discomfort associated with diaphoresis To increase the client's sense of control and lessen her fear

To increase the client's sense of control and lessen her fear Rationale When the client is anxiously anticipating the labor and birthing process, the nurse should share information about vital signs and the fetal heart rate with the client. This helps reduce the client's fear and anxiety about labor and the birthing process. It also helps give the client an increased sense of control, and this is essential during labor. The client is comforted and provided with support when the nurse encourages family members to be present during the labor process. Providing information about vital signs and the fetal heart rate may lessen the client's anxiety, but may not provide physical comfort. The nurse educates the client about labor pains prior to labor; however, the intervention of sharing information about vital signs and the fetal heart rate is not focused on educating the client. To relieve the discomfort associated with diaphoresis, the nurse provides comfort measures such as frequent mouth care, application of a damp cloth to the forehead, and changing a damp gown or bed covers

The nurse caring for a client in labor asks the support person to use heat application for pain relief. Why is heat applied to the body? To relieve muscle spasms To relax anesthetized areas To relieve general backache To provide comfort in the chest

To relieve general backache Rationale The application of heat enhances relaxation and reduces pain during labor. Heat application is effective for general backache from fatigue or back pain caused by a posterior presentation. Cold applications, such as cold cloths, frozen gel packs, or ice packs, may be applied to relieve muscle spasms. Cold, not heat, is applied to the chest to increase comfort when the client feels warm. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged.

interventions spinal anesthesia during maternal hypotension

Turn women to lateral position or place pillow under hip to displace uterus Maintain IV infusion, or increase Administer oxygen by nonrebreather mask at 10 to 12L/min Elevate legs Notify MD Administer IV vasopressor (eg. ephedrine 5 to 10 mg or phenyliphrine 50 to 100mcg) Remain with woman before administration - vital signs 20-30 min before

A client is taking fentanyl citrate (Sublimaze) for labor pain. The nurse finds that the client has also been prescribed naloxone (Narcan) PRN. What is the purpose of naloxone? To promote more rapid birth To increase uterine contractions To reverse the central nervous system (CNS) depressant effects To relieve pain if fentanyl is ineffective

To reverse the central nervous system (CNS) depressant effects Rationale Fentanyl citrate (Sublimaze) is a short-acting opioid narcotic agonist analgesic that may cause central nervous system (CNS) depression. Therefore, the nurse may need to administer naloxone (Narcan), an opioid antagonist that promptly reverses the CNS depressant effects. An opioid antagonist is helpful to relieve pain when a more rapid birth is anticipated. Opioids inhibit uterine contractions. Fentanyl citrate (Sublimaze) has a short duration of action, and more frequent dosing is required if the pain is not relieved in one dose.

Tocolytic Therapy

Tocolysis= relaxation of the uterus -administration of drugs that inhibit uterine contractions -administered when maternal position change and discontinuance of an oxytocin infusion have not diminished the uterine contractions effectively -most commonly used tocolytic is terbutaline (Brethine)

Display- Top vs. Bottom

Top- FHR Bottom- Uterine activity -Each small square on monitor paper represents 10 seconds -Each larger box of 6 squares equals 1 minute

A patient is in the first stage of labor and in severe pain. Which actions, made by the nurse, are appropriate to comfort this patient? Select all that apply. Touch the arm. Ask if there is a birth plan. Incorporate the patient's cultural practices. Only include the necessary caregivers in the room. Limit analgesics so the patient can best respond to contractions.

Touch the arm. Touch can communicate acceptance and reassurance and can provide physical and emotional comfort to many laboring women. Correct Ask if there is a birth plan. A birth plan describes the patient's preferences. It may be very simple or it may be a list of specific expectations. Correct Incorporate the patient's cultural practices. The nurse should incorporate a family's cultural practices into care as much as possible. Correct Only include the necessary caregivers in the room. The number of different caregivers should be limited as much as possible and the patient should know who each caregiver is and their respective roles.

A client has been laboring for several hours and after checking the client's cervix, the nurse finds the client's cervix is dilated 9 cm and is having strong uterine contractions (UCs) each lasting for 45 to 90 seconds. Based on these observations, the nurse determines that the client is in which stage of labor? Latent phase of the first stage of labor. Active phase of the first stage of labor. Active stage of the second stage of labor. Transition phase of the first stage of labor.

Transition phase of the first stage of labor. Rationale The first stage of labor consists of three phases: the latent phase, active phase, and transition phase. Strong UCs and cervical dilation of 8 to 10 cm can be observed during the transition phase of labor. Moderate to strong UCs and cervical dilation of 4 to 7cm can be observed during the active phase of labor. Mild to moderate UCs and cervical dilation of 0 to 3 cm can be considered as the latent phase of labor. The second stage is known as the fetal expulsion stage. It begins when the cervix is fully dilated and ends when the baby is born.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? Encourage her to empty her bladder. Decrease her intravenous (IV) rate to a keep vein-open rate. Turn the woman to the left lateral position or place a pillow under her hip. No action is necessary because a decrease in the woman's blood pressure is expected.

Turn the woman to the left lateral position or place a pillow under her hip. Rationale Turning the woman to her left side is the best action to take in this situation because this will increase placental perfusion to the infant while waiting for the doctor's or nurse-midwife's instruction. Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

Three things to do after external version has been completed:

a. Perform a nonstress test to evaluate fetal well-being. b. Monitor for uterine activity, bleeding, ruptured membranes, and decreased fetal activity. c. With Rh-negative clients, perform Kleihauer-Betke test as prescribed to detect the presence and amount of fetal blood in the maternal circulation and to identify clients who need additional Rho(D) immune globulin.

clinical significance late descelerations

fetal hypoxemia acedimia low apgar scores considered ominus if persistent and uncorrected, especially when associated with absent or minimal baseline variability

somlia

Women are extremely stoic during childbirth because they do not want to show any sign of weakness.

bear down

Women who are laboring without regional anesthetics can experience an irresistible urge to __ __ before full dilation Will result in cervical edema and lacerations, as well as slow the labor process.

support

Women who have continuous labor __ are more likely to have a spontaneous vaginal birth and are less likely to have intrapartum analgesia or anesthesia, a cesarean or an operative vaginal birth, and a baby with a low 5-min APGAR score' or to report dissatisfaction with their childbirth experiences

women with strong religious belief

Women with strong religious beliefs often accept pain as a necessary and inevitable part of bringing a new life into the world, whereas others tend to vocalize their pain by moaning, breathing rhythmically, or shouting.

ROM

You must assess the FHR after __ because this is the most common time for the umbilical cord to prolapse, after any change in the contraction pattern or maternal status, and before and after the woman receives medication or a procedure is performed.

Bloody show

_ __ is distinguished from bleeding by the fact that it is pink and feels sticky because of its mucoid nature.

general anesthesia

_ is rarely used for vaginal birth. Very emergent c/s; Usually try to use spinal first General anesthesia may be necessary if a spinal or epidural block is contraindicated or if circumstances necessitate rapid birth (vaginal or emergent cesarean) without sufficient time or available personnel in the birth setting to perform a block.

Uterine contractions"

__ The primary powers of labor that act involuntarily to expel the fetus and the placenta from the uterus."

Sitting

__ is not contraindicated unless it adversely affects the fetus.

Squatting

__ is one of the best and most natural positions for second stage labor and has been associated with the same benefits as other upright and lateral positions

Acme

_____ The peak of a contraction with an intrauterine pressure less than 80 mm Hg."

Intensity "

_________________ The strength of a contraction at its peak."

Resting tone "

__________________ The tension of the uterine muscle between contractions."

Bearing-down effort

______________________ An involuntary urge to push in response to the Ferguson reflex."

factors determining the presenting part

fetal lie fetal attutude extension/felxion of the fetal head

presentation/presenting part

fetal position indicates that portion of the fetus that overlies the pelvic inlet

stations of presenting part

relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birthing canal measured in cm above or below the ischial spines lowermost - 1 cm above the spines (-1) level of the spines (0) 1 cm below spines (+1) birth immenent ar +4 to+5 cm

interventions during latent 2nd satge

helpt to rest in position of comfort promote progress of fetal decent and onset of urge to bear down by encouraging position change, pelvic rock, ambulating, showering

Nubain (Nalbuphine)

opioid agonist antagonist stimulates kappa, blocks mu moderate to severe pain IV or IM duration 2-4 hrs

uterus after labor began

contractions cause uterus to have a thick and muscular upper segment and thin walled passive lower segment separated by physiologic retraction ring

Primary powers of labor

contractions moving downward over uterus in waves and described by - frequency - duration - intensity responsible for effacement

biofeedback for labor

control of recognizing and controling body responses

pelvic cavity/midpelvis

curved passage with a short anterior wall and much longer concave posterior wall bounded by the posterior aspect of the symphasis pubis, the ischium, a portion of ilium, the sacrum, coccyx

secondary powers

expulsive contractions after presenting part reached pelvic floor bearing down no effect on cervical dilation

Tocotransducer

external monitoring instrument that measures uterine activity transabdominally. It is placed over the fundus

ultrasound transducer

external monitoring instrument that works by reflecting high frequency sound waves off the fetal heart and valves to assess and record the FHR pattern. It is placed over the area of maximal intensity of FHR after conductive gel is applied to its surface

Which test is performed to determine if membranes are ruptured? Urine analysis Fern test Leopold maneuvers Artificial rupture of membranes (AROM)

fern test Rationale In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

Which area does the nurse assess to hear loud, clear fetal heart sounds? Fetal head Fetal back Fetal neck Fetal abdomen

fetal back Rationale The nurse must locate the fetal back to listen and count the heart sounds. The heart sounds are loudest and clearest over the fetal back. It is difficult for the nurse to count the heart sounds over the fetal head, neck, or abdomen because the heart sounds are not loud and clear in these areas.

Extension of labor

fetal head reaches perineum, deflected anteriorly by the perineum, occiput passes under the lower border of the symphisis pubis first and the head emerges by extension - occiput, face, chin

moderate variability

fetal heart rate fluctuations are 6-25 beats/min

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: either hot or cold applications may provide relief, but they should never be used together in the same treatment. acupuncture can be performed by a skilled nurse with just a little training. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. Rationale The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: either hot or cold applications may provide relief, but they should never be used together in the same treatment. acupuncture can be performed by a skilled nurse with just a little training. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. Rationale The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

hands-poised approach (birth of head)

hands are prepared to place light pressure on the fetal head to prevent rapid expulsion; does not place hands on the perineum or use them to assist with birth of the shoulders or body

Variable Deceleration- what they mean

have little clinical significance unless recurrent -recurrent variable decelerations indicate repetitive disruption in the fetus's oxygen supply -most commonly found during the transition phase of the first stage of labor or the second stage of labor as a result of umbilical cord compression

Baseline Fetal Heart Rte

he average rate during a 10-minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 beats/minute -after 10 minutes of tracing, observe the approximate mean heart rate and round to nearest 5 beats/min

early desceleration cause

head compression from - uterine contractions - vaginal examination - fundal pressure - placement of internal mode of monitoring

asynclitism

head usually engages into the pelvis parallel to the anteroposterior plane of the pelvis asynclisism - the head is deflected anteriorly or posteriorly in the pelvis extreme asynclisism causes cephalopelvic disproportion, because head is positioned that it cannot descend

physical examination/ labor

heart lungs skin edema ( face, hands, sacrum, legs) tendon reflexes vitals ( temp, pulse, RR, BP)

interventions during active pushing 2nd stage

help to change positions encourage spontanous bear down help to relax and conserve energy provide comfort and pain relief coach to pant and gently push between contractions provide emotional support keep woman informed create a calm and quite environment offer mirrowr to watch birth

Gate-control theory of pain

helps explain the way hypnosis and the pain relief techniques taught in childbirth preparation classes work to relieve the pain of labor; using distraction techniques such as massage or stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. sensations travel along sensory pathway to the barain but only limited number of sensations can travel through these nerves pathaways at a time

Naloxone (Narcan)

opioid antagonis indication - opioid induced respiratory depressionor pruritus from epidural IV or IM IV for overdose 0.4-2 mg IV route foe newborns preferred 0.1 mg/kg to 1 mg/ml

nursing interventions nitrous oxide

observe for nausea, vomiting dizziness, drowziness fast relief, doesnt affect fetus

assessment during 4th stage of labor lochia

observe on pad and under buttocks determine amount and color note size and number of clots note odor observe perinium for source of bleeding

back labor

occiput posterior or transverse position helps - hands and knees position or side lying position in the tub ( water is less energy used to turn) no limit in time, can use after raptured membrane she should come out if her temperture and FHR increase water temp 36C warm water can cause dizziness - provide stool and assistance in and out

crowning

occurs when the widest part of the head (biparietal diameter) distends the vulva just before birth

vaginal vault laceration

often circular and may result from use of forceps to rotate the fetal head, rapid fetal descent, or precipitous birth; additional injury that may occur high near the level of the ischial spines

Aromatherapy

oils distilled from plants to balance mind, body, spirit mix with lotions before applying to skin, or dropped to bath, on pillow lavender, rose, jasmine - relaxation and reduce pain rose - antidepressant and uterine tonic jasmine strengthens contractionsa, decrreases feeling of panic bergamot and and rosemary

priorities for recovery room after general anesthesia

open airway maintain cardiopulmonary function prevent postpartum hemorrhage pain meds after they are consciousness

Meperidine

opioid agonist cross placenta - prolonged sedation and neurobehavioral changes in fetus for a lomg time due to long half life ( 2-3 days) cannot reverse with naloxone moderate to severe pain 100 mg meperidine = 10 mg morphine

Stadol (butorphanol tartrate)

opioid agonist - antagonist moderate to severe pain IV or IM

first stage meds

opioid agonist analgesics opioid agonist-antagonist analgesics epidural block anesthesia combined spinal-epidural analgesia

labor prep

position woman clean vulva and perineum monitoring status prepare oxytocin to give right after placenta full protective gear like for surgery - cap, mask, gown, boots, gloves woman draped with sterile drapes

ledeading cause of cerebral palsy

prematurity intrapartum asphyxia

acupressure and acupuncture

pressure, heat or cold applied to points called tsubos ( have increased density of neuroreceptors and increased electrical conductivity) simultaneously with breathing is the best acupuncture puts needles to restore qi ( energy)

descend

progress of the presenting part through the pelvis

if head diameter exceeds limits of maternal pelvis

prolonged labor forcepts vacuum-assisted birth c-section

fetal presentation

refers to the relationship of hte fetal presenting part to the four quadrants of the maternal pelvis.

Station

refers to the relationship of the fetal presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters above or below the ischial spines, serving as a method of determining the progress of fetal descent.

Fetal lie

refers to the relationship of the fetal spine (long axis) to the maternal spine (long axis). Longitudinal lie is used when the spines are parallel. Transverse lie is used when the spines are perpendicular.

woman after vaginal birth

regular diet asap

fetal attitude

relation of the fetal body parts to one another

fetal lie

relation of the long axis (spine) of the fetus to the long axis (spine) of the mother

to keep woman unconscious

propofol etomidate ketamine

After reviewing the urinalysis reports of a pregnant client, the nurse finds that the patient has preeclampsia. What did the nurse find in the client's urinalysis report? Nitrites Ketones Proteins Leukocytes

proteins Rationale Urinalysis of the patient during pregnancy helps to assess the client's health. The presence of proteins in the urine indicates that the client may have complications, such as preeclampsia. The presence of ketones in the urine sample indicates that the client has improper nutrition. The presence of leukocytes and nitrates in the urine indicates that the client has infection.

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: visceral. referred. somatic. afterpain

referred. Rationale As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

Ferguson reflex

refers to the maternal urge to bear down, which occurs when the fetal presenting part reaches the perineal floor stimulation stretch receptors and causing release of oxytocin.

Cardinal Movements

refers to the movements of the fetus in a vertex presentation as it turns and adjusts its head to facilitate passage through the maternal birth canal. 7 terms: engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion

Presenting part

refers to the part of the fetal body that is first felt by the examining finger during a vaginal examination. The four types are occiput, mentum (chin), sacrum, and scapula

Vertex position

refers to the presentation that occurs when the fetal head is fully flexed, making the fetal occiput the part first felt by the examining finger

Which of the following statements is used to describe a characteristic of a uterine contraction? Select all that apply. Frequency (how often contractions occur) Intensity (the strength of the contraction at its peak) Resting tone (the tension in the uterine muscle between contractions) Appearance (shape and height) Attitude (the way the uterus presents itself)

requency (how often contractions occur) Intensity (the strength of the contraction at its peak) Resting tone (the tension in the uterine muscle between contractions) Rationale Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not a term used to describe contractions. Duration is another characteristic of uterine contractions. Uterine contractions are described in terms of frequency or how often the contractions occur. Uterine contractions are described in terms of intensity (the strength of the contraction at its peak). Uterine contractions are described in terms of resting tone (the tension in the uterine muscle) or attitude (the way the uterus presents itself).

other important infor

respiratory status allergies Because __ and __ can complicate otherwise normal labor, the nurse should record the woman's most recent solid and liquid intake infant feeding info pain relief methods cultural expectations photo video

Internal Rotation

rotation of the fetus occurs most commonly from the occipitotransverse position, assumed at engagement into the pelvis, to the occipitoanterior position while continuously descending.

meperidine nursing considerations

safety measures (rails, assistance ambulation) do not give if birth will be 1-4 hr after administration, so child doesnt have respiratory depression

fetal head membranous sutures

sagittal lambdoidal coronal frontal

Nubain (Nalbuphine Hydrochloride) adverse effects

sedation drowziness nausea and vomiting dizziness respiratory depression temporary absent or minimal FHR variability

fentanyl adverse effects

sedation respiratory depression nausea and vomiting

fentanyl

short acting opioid agonist rapidly crosses placenta ( i min after IV) same analgesia with fewer fetal side effects used due to - rapid onset - short half-life - lack of metabolites usually PCA moderate to severe

expectations aftwr epidural anesthesia

should be able to raise legs extend t\at the knees off the bed flex her knees place her feet flat on the bed raise her buttocks well off the bed no numbing, tingling

spinal anesthesia precaution

should wear mask during the procedure. (marked hypotension, impaired placental perfusion and ineffective breathing pattern may occur during spinal anesthesia) Must have bolus of 500 to 1000 LR or NS prior to spinal or epidural - decreases risk for hypotension)

shoulder presentation

shoulder first 1 %

spinal anesthesia (block)

single-injection, subarachnoid anesthesia useful for pain control during vaginal or cesarean birth but not for labor`

suboccipitobregmatic diameter

smallest anteroposterior diameter of the fetal skull to enter the maternal pelvis when the fetal head is in complete flexion 9.5 cm term

fundal pressure

the application of gentle, steady pressure against the fundus of the uterus to facilitate the vaginal birth; not advised because there is no standard technique available

engagement of presenting part

the largest transverse diameter of the presenting part has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0 determined by vaginal or abdominal examination

Engagement

this is said to have occurred when the largest transverse diameter of the presenting part has passed through the pelvic inlet and into the true pelvis, reaching the level of the ischial spines.

touch and massage

touch - holding hand, stroking her body, embracing her abused women might not want it therapeutic touch- concept of energy field within the body called prana and uses laying on hands to redirect energy fields associated with pain head, hand, back, foot massage may be effective

occipital bone

triangular 1 x 2 closes 6-8 weeks after birth

bony pelvis

true false

assessment during 4th stage of labor perinium

turn woman to her side and flex upper leg on hip lift upper buttock observe perinium assess episiotomy or laceration for redness, edema, echhymosis ( bruising), drainage and approximation assess for presence of hemorrhoids

Fetal head bones

two parietal two temporal frontal bone occipital bone

referred pain

type of pain felt in areas of the body other than the area of pain origin. During labor and birth, pain originating in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, gluteal area, and down

visceral pain

type of pain that predominates during the first stage of labor and is located over the lower abdomen; it results from cervical changes, distention of the lower uterine segment and uterine ischemia

somatic pain

type of sharp, intense, burning pain that predominates during the second stage of labor; it results from stretching and distention of perineal tissues and the pelvic floor to allow passage of the fetus, from distention and traction on the peritoneal and uterocervical supports during contractions, and from lacerations of soft tissues.