Family Centered Nursing Exam 2
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents?
"Ask your 2-year-old to pick out a special toy for his sister."
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?
"I feel pressure in my vagina when I have the contraction."
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. How should the nurse respond?
"Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed."
What vitals during labor are an instant concern for hemorrhage? (2)
-BP dropping -BP Dropping + Increased pulse = HUGE HEMORRHAGE CONCERN
Describe the Active Phase of Stage 1 of labor (4)
-Begins at 6 cm of dilation, and cervical dilatation becomes more rapid. -Stronger, more frequent contractions (every 3-5 minutes). -Show (increased vaginal secretions) and spontaneous membrane rupture. -Exciting and frightening time for mom.
Describe the Latent Phase within Stage 1 of labor (3)
-Begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins. -Contractions are mild and short (20-40 seconds) -Cervical effacement + minimal dilation occurs
Describe the Transition Phase of Stage 1 of labor (4)
-Contractions reach their peak intensity (every 2-3 minutes) -Maximum dilatation of 8-10 cm occurs. -If it has not previously occurred, show will occur as the last of the mucus plug is released. -Client may experience nausea and vomiting, anxiety, panic, or irritability.
Women with a history of __________ or __________ are at a higher risk of ectopic pregnancies.
-Endometriosis -Recurrent pelvic infections
What assessments can be made to identify an ectopic pregnancy? (4)
1. Vaginal bleeding: caused by breaking and ripping tissue as the baby grows in the fallopian tube and it ruptures. 2. Abdominal pain: Indicates rupture, as blood pooling into the abdomen is extremely painful. 3. Ultrasound or MRI to diagnose 4. Cullen sign if caught late (superficial bruising/blue-tinged umbilicus)
What is the normal baseline range for fetal heart rate?
110-160 BPM
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:
7.15 or less
What is macrosomia?
A large baby for gestational age (>8 lbs 13 oz)
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?
A positive nitrazine test
When should cervical assessments be completed for a patient in labor?
After the contraction.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis
What are late decelerations in relation to FHR?
An ominous and potentially disastrous non-reassuring sign. Indicates uteroplacental insufficiency. -Onset occurs at peak of contraction. -May indicate fetal distress if repetitive or severe.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
Applying ice. Rationale: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk.
What intervention should be done by the labor nurse immediately following the patient's water breaking?
Assess fetal heart rate.
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
Assess vital signs. Rationale: The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress.
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 beats/min The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. A. Opioid medication to maternal client B. Fetal movement C. Fetal distress D. Uteroplacental insufficiency E. Maternal fever
B. Fetal movement C. Fetal distress D. Uteroplacental insufficiency E. Maternal fever Rationale: An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency. Opioids would lead to fetal bradycardia.
A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns what color?
Blue.
What should be suggested to relieve pain in early labor?
Breathing techniques.
The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply. A. Heart rate: 82 bpm B. Pulse oximeter: 95% C. Fetal heart rate 198 bpm D. Blood pressure: 120/78 mm Hg E. Urine output: 20 ml/hr
C. Fetal heart rate 198 bpm E. Urine output: 20 ml/hr Rationale: Assessment parameters of hemodynamic stability include heart rate, blood pressure within normal limits, urine output greater than 30 ml/hr, and continuous fetal heart rate monitoring with a rate between 120 and 160 bpm. In this situation, the client's low urine output and high fetal heart rate are signs of being hemodynamically unstable.
A patient in the second stage of labor says that she feels rectal pressure and like she has to use the bathroom. What action by the nurse should be taken immediately?
Check cervical dilation. This is a sign that the baby is coming.
What are decelerations in relation to FHR?
Decelerations are a visually apparent change in the FHR below the baseline. They can be benign or nonreassuring. -Onset varies with contractions -Extremely common; present in 83% of labors.
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?
Difficulty breathing
How should the nurse ease the patient's anxiety when they are in labor?
Discuss why the patient is anxious.
What is dilatation of the cervix? What causes dilatation to occur? (2)
Enlargement or widening of the cervical canal from an opening of a few millimeters to wide enough to fit the fetus (10cm). Dilatation occurs because: 1. Uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting parts of the fetus. 2. Fluid-filled membranes push ahead of the fetus and serve as an opening wedge.
What is the difference between external and internal fetal monitoring?
External: Ultrasound. Internal: Tiny screw attached to an electrode that is placed into a superficial layer of the fetus's scalp. Typically only used if external monitoring is questionable.
What is fetal heart rate variability?
FHR variability is the difference between the highest and lowest rates shown on a strip. Natural fluctuations happen when the fetus moves or sleeps. If no variability is present, that indicates that the natural pacemaker activity of the fetal heart may be affected. -It is one of the most reliable indicators of fetal well-being.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours.
Describe Stage 2 of labor
From full dilation and cervical effacement to birth. Baby is engaged, locked and loaded, and born.
Describe Stage 3 of labor -What are the two phases of this stage?
From the birth of the infant to the delivery of the placenta. Phase 1: Placental Separation Phase 2: Placental Expulsion
What is gestational hypertension? What is the difference between gestational hypertension, preeclampsia, and eclampsia?
Gestational hypertension: Vasospasms as a result of increased blood volume. -A patient has gestational hypertension when they have an elevated blood pressure (140/90) at 20 weeks gestation but no proteinuria or edema. -Preeclampsia is hypertension + proteinuria + edema. -Eclampsia occurs when a seizure results from preeclampsia.
HELLP Syndrome -What is it? -Biggest "Jason" -How do we treat it?
HELLP = Hemolysis, Elevated Liver enzymes, and Low Platelets. A serious, often fatal variation of the gestational hypertensive process. Biggest Jason: Bleeding/DIC Tx: Fresh frozen plasma to help with clotting factor.
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia?
Have her blood pressure checked at every prenatal visit. Rationale: Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive.
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
Less than 3 hours
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses "arrest of labor." The woman asks, "Why is this happening?" Which response is the best answer to this question?
More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
In the delivery process, if the mom has a heart dysrhythmia, what is the priority concern for the fetus?
Oxygenation issues
What nursing action helps establish whether the fetal head is in a favorable position for vaginal birth or not?
Palpating for fontanelle spaces through the dilated cervix during a pelvic examination.
A patient in labor is fully effaced and 8cm dilated. What will be suggested for the next contraction?
Panting technique.
A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?
Part of the fetal body entering the maternal pelvis first.
What are the primary and secondary powers of labor?
Primary: Uterine contractions Secondary: Abdominal muscles. **Patients should not bear down with their abdominal muscles to push until the cervix is fully dilated.
General Anesthesia for Labor -Pros (1) -Cons (1)
Pros: 1. Though not ideal, it is helpful in instances of emergency c-section, or if there is trouble placing the epidural. Cons: 1. Risk of hypoxia and possible inhalation of vomitus during administration.
A patient in labor has higher blood pressure than what is typical for them and seems concerned. What should the labor nurse do?
Retake the blood pressure in 15 minutes.
What would you tell a parent who is asking about the benefits of rooming in with their newborn?
Rooming in is encouraged, as it helps the parents better pick up on the baby's cues.
Shoulder Dystocia -What is it? -Assessments (1) -Interventions (3)
Shoulder Dystocia: Baby's shoulders are stuck on pelvic bone. Assessments: -Turtle Sign: Baby crowning, then going back into the vagina repeatedly. This is a medical emergency. Interventions: -Suprapubic pressure -C-section if caught early enough -McRoberts maneuver (pictured): push mom's legs up to ears.
What maternal blood pressure level is expected during labor? What levels are concerning and should be reported?
Slightly increased while pushing and straining is normal, but only a little. -A systolic blood pressure greater than 140 and diastolic greater than 90, or an increase in systolic more than 30 or diastolic more than 15 should be reported. -Falling blood pressure should also be reported, as it could be a concern more hemorrhage.
What is terbutaline used for in an OB setting?
Slows/stops uterine contractions to help prevent premature labor.
What is the ideal presentation for the fetus to help it pass through the pelvis most easily?
Suboccipitobregmatic position: complete flexion of chin to chest.
What are the three components of the passage?
The cervix, vagina, and pelvis.
What is the preeclampsia triad? (3)
Triad: 1. Blood pressure >140/90 2. Proteinuria 3. Edema with vasospasm as a cause
Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding?
Two fingerbreadths below the umbilicus
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra.
When is the ideal time for an epidural?
When mom is 3-5 cm dilated is best. At 8-9 cm, positioning can be too difficult.
What interventions are available for ectopic pregnancies? (3)
1. Laparoscopic surgery: evacuates the pooling blood in abdomen. 2. Methotrexate: to evacuate pregnancy 3. Vacuum aspiration (abortion)
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
Fetal status
Psychologically, women who manage best in labor typically have ___________ and ______________.
-Strong self-esteem -A meaningful support person with them.
How might sexual intercourse help induce labor?
Semen contains prostaglandins which soften or "ripen" the cervix. If a cervix is ready to ripen, the combination of prostaglandins plus the rhythmic contractions brought on by female orgasm might help stimulate contractions.
What is effacement of the cervix?
Shortening and thinning of the cervical canal to ensure that tearing does not occur during labor.
What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?
Starting an IV and hanging IV fluids Rationale: Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%)
What assessments can be observed for a patient with abruptio placentae? (4)
1. Sharp, stabbing pain 2. Tenderness 3. Blood pooling 4. Couvelaire uterus: uterus is tense and rigid.
After the infant is born, how soon will skin-to-skin contact be initiated?
Immediately. APGAR and cutting the umbilical cord can be performed during skin-to-skin.
Fentanyl -Indications (1) -Side effects (3)
Indications: -Pain control during labor Side Effects: -Hypotension -Respiratory depression -Slows labor if given too early
Oxytocin (Pitocin) -Indications (2) -Side Effects (1)
Indications: -Encourages uterine involution -Helps to induce labor Side Effects: -Can increase BP
At what time is the laboring client encouraged to push?
When the cervix is fully dilated
What are the leading complications related directly to pregnancy? (5)
1. Hemorrhage 2. Thromboembolism 3. Infection 4. Hypertension of pregnancy 5. Ectopic pregnancy
What are four fetal danger signs of labor?
1. High or low fetal heart rate 2. Meconium staining 3. Hyperactivity 4. Low oxygen saturation (normal is 40-70%)
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
"Ovulation may return as soon as 3 weeks after birth."
A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best?
"Please come in now for an evaluation by your healthcare provider." Rationale: Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully.
The fetal heart rate (FHR) should be assessed: -Every _______ minutes beginning latent labor -Every _______ minutes during active first stage labor -Every ________ minutes during second stage labor
-Every 30 minutes beginning latent labor -Every 15 minutes during active first stage labor -Every 5 minutes during second stage labor
What is fetal attitude? What is the optimal fetal attitude?
-The degree of flexion a fetus assumes during labor or the relation of fetal parts to each other. -Optimal: Complete flexion "fetal position."
Because of a disproportion between the fetus and the passage, a woman is unable to deliver her baby vaginally. The labor knows knows that the structure responsible for this is most likely ___________. How does the labor nurse approach this discussion with the parents?
-The pelvis. -Inform the parents that the reason they are unable to have a vaginal birth is most likely due to either the pelvis being too narrow or the fetus not presenting at the birth canal at its narrowest diameter. Implying that the baby's head is too large for a vaginal birth is rarely true and causes parents to worry that something is wrong with their baby.
What are the four leading causes for bleeding during pregnancy?
1. Abortion (miscarriage) 2. Ectopic pregnancy 3. Placenta previa 4. Abruptio placenta
Nursing Interventions for Third and Fourth Stages of Labor (5)
1. Administer oxytocin: encourages uterus to clamp down, preventing hemorrhage. 2. Placental delivery 3. Assess site of perineal repair if tearing/episiotomy 4. Massaging the fundus 5. Educate about postpartum bleeding
What parameters should the nurse use to assess lochia? (5)
1. Amount: Varies greatly per patient, but saturating a perineal pad in less than 1 hour is an abnormally heavy flow and should be reported. 2. Consistency: Exceedingly large clots are abnormal. 3. Pattern: Should follow sequence of rubra to alba, and not go backward. 4. Odor: Offensive odor can be indicative of infection. 5. Absence: Should not be absent. This can be indicative of infection.
What interventions can be done for moms with gestational hypertension/preeclampsia/eclampsia? (6)
1. Antiplatelet therapy with low-dose aspirin 2. Antihypertensives 3. TED hose to increase circulation 4. Decreasing stress levels, bed rest if necessary 5. Magnesium Sulfate: relaxes vasculature 6. Monitor fetal wellbeing via doppler, nonstress test, or biophysical profile.
What assessments should be done to monitor for gestational hypertension/preeclampsia/eclampsia? (5)
1. BP (duh.) 2. Protein urine levels 3. Liver enzymes 4. Monitor mom's weight for pitting edema, fluid retention. 5. Assess mom for headaches.
What signs and symptoms would you see in someone with mild preeclampsia? (4)
1. BP is 140/90 or systolic elevated over 30 mmHg or diastolic elevated over 15 mmHg from pre-pregnancy level. 2. Proteinuria of 1+ to 2+ on a random sample. 3. Weight gain over 2 lbs/week in second trimester and 1 lb/week in third trimester. 4. Mild edema in upper extremities or face.
What signs and symptoms would you see in someone with severe preeclampsia? (9)
1. BP is 160/110 2. Proteinuria is 3+ to 4+ and 5 g on a 24-hr sample. 3. Oliguria or altered renal function tests 4. Cerebral or visual disturbances 5. Pulmonary or cardiac involvement 6. Extensive peripheral edema, significant pitting edema, facial edema. 7. Hepatic dysfunction 8. Thrombocytopenia 9. Epigastric pain
What are signs of false labor? (5)
1. Begin and remain irregular 2. Felt first abdominally and remain confined to the abdomen and groin. 3. Disappear with sleep or ambulation. 4. Do not increase in duration, frequency, or intensity. 5. Do not achieve cervical dilation.
What are signs of true labor? (5)
1. Begin irregularly, but become regular and predictable. 2. Felt first in lower back, then sweep around to the abdomen in a wave. 3. Continue regardless of patient's activity. 4. Increase in duration, frequency, and intensity. 5. Achieve cervical dilation.
What are some examples of alternative (non-pharmacologic) therapies for pain management during labor? (7)
1. Breathing techniques 2. Aromatherapy 3. Reflexology 4. Hydrotherapy 5. Meditation 6. Acupuncture 7. Acupressure
What changes does the uterus go through during the postpartum period? (3)
1. Clamping down of vasculature to seal off where placenta was implanted (necessary to prevent hemorrhage). Accomplished by contractions after the placental delivery to pinch off blood vessels. Palpation and massage encourage this process! 2. Uterus shrinks back to pre-pregnancy size, which can take up to 6 weeks. 3. (As pictured) The fundus will go from being at the level of the umbilicus to decreasing by 1 cm or fingerbreadth per day. By the 8th day, it should be all the way down to the symphysis pubis.
Assessments for prolapsed umbilical cord (3)
1. Decreased FHR during contractions 2. Palpation of cord on examination of sutures 3. Decreased fetal heart tones
Interventions for prolapsed umbilical cord (3)
1. Document how long without fetal heart tones 2. Elevate mom's hips to take pressure off or place in Trendelenburg. 3. C-section
What signs and symptoms would you see in someone with eclampsia? (2)
1. Either seizure or coma, accompanied by signs and symptoms of preeclampsia. 2. Fetal death can result from maternal circulatory collapse, due to lack of oxygen.
What interventions are available for macrosomia? (2)
1. Elective c-section 2. Early induction
Nursing interventions for Latent Phase in Stage 1 of labor (3)
1. Encourage controlled breathing. 2. Encourage patients to walk around and make preparations for birth. 3. Analgesics can be administered; but if desired, alternative pain relief methods could also be used, such as aromatherapy, distraction, or acupressure.
What should be included in an assessment of the fetus during labor? (5)
1. FHR and uterine contractions 2. FHR patterns: adequate recovery after contractions? 3. Baseline FHR 4. Variability: a happy baby is a moving baby. 5. Monitor for decelerations
What are some common maternal concerns and feelings in the postpartum period? (3)
1. Feeling overlooked or forgotten: transition from the attention during pregnancy to the baby getting all of the attention. 2. Disillusionment: the baby isn't what they expected. 3. Postpartum blues: as many as 50% of patients experience feelings of overwhelming sadness due to hormonal changes, exhaustion, and physical discomfort. **Important to assess whether it's more than postpartum blues, as some patients can experience postpartum depression or even psychosis.
What assessments are made to identify macrosomia? (3)
1. Fundal height 2. Biophysical profile (more involved ultrasound) 3. Screening for gestational diabetes (biggest cause of macrosomia).
What should be included in an assessment of the mom during the first stage of labor? (6)
1. History: any gynecological issues, psychological issues, previous pregnancies. 2. Physical exam 3. Leopold maneuvers: systematic method of observation and palpation to determine fetal presentation and position as part of a physical examination. 4. Rupture of membranes: when did the water break? What time? Duration? Odor? Amount? 5. Vaginal exam 6. Sonogram to check the position of the fetus.
What are the signs and symptoms of hemorrhage/hypovolemic shock? (7)
1. Increased pulse 2. Decreased BP 3. Increased respiratory rate 4. Cold, pale, clammy skin 5. Decreased urine output 6. Dizziness/decreased LOC 7. Decreased central venous pressure
What are the benefits of having an effective doula? (4)
1. Increased self-esteem 2. Faster labor process 3. Improve breastfeeding success 4. Decrease rates of oxytocin augmentation, epidural anesthesia, cesarean birth, and postpartum complications.
What are the three phases of contractions?
1. Increment (when the intensity increases) 2. Acme (contraction is at its strongest) 3. Decrement (when the intensity decreases)
What are the primary types of lochia? (3)
1. Lochia Rubra: First 1-3 days. Mainly blood, tissue, debris. Small clots are normal. Golf ball-sized clots are concerning. 2. Lochia Serosa: Lasts 4-10 days. Pinkish-brown discharge that's more watery than bloody. Less clotting or no clots. 3. Lochia Alba: 3rd or 4th week. Clear mucous secretion of uterine glands.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? (4)
1. Low self-esteem 2. Feeling overwhelmed and out of control 3. Low socioeconomic status 4. Lack of social support
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? (3)
1. Oxytocin 2. Progesterone 3. Prostaglandins
What are the 4 P's of successful labor?
1. Passage (pelvis): should be of adequate size and contour. 2. Passenger (fetus): should be appropriate size and in an advantageous position and presentation. 3. Powers (of labor): uterine factors are adequate. 4. Psyche: based on pregnant person's past life experiences and psychological state.
What are some interventions for hemorrhage/hypovolemic shock? (6)
1. Place patient flat on their side for optimal placental and renal function. 2. IV fluids, such as LR 3. Administer O2 as necessary 4. Monitor contractions and FHR 5. Withhold fluid in case of emergency c-section 6. Measure I&Os and blood loss via perineal pads
Nursing Interventions for Second Stage of Labor (7)
1. Preparing for birth 2. Positioning for birth 3. Encouraging pushing 4. Perineal cleaning: helps keep skin moist to anticipate stretching. 5. Answering any questions about episiotomies. 6. Help start the bonding process after birth. 7. Cutting and clamping the umbilical cord.
What are the progressive maternal changes that occur during the postpartum period? (3)
1. Production of milk 2. Restoration of normal menstrual cycle 3. Beginning of parenting role
What interventions are needed for a patient with abruptio placentae? (5)
1. Rapid fluid replacement 2. O2 to limit fetal anoxia 3. Monitor fetal heart sounds externally and record vitals every 5-15 minutes to observe progress. 4. No abdominal, vaginal, or pelvic examinations. 5. Prepare for cesarean delivery
Nursing Interventions for First Stage of Labor (6)
1. Respect contraction time: do not interrupt a client in the middle of breathing exercises. 2. Helping change positions 3. Promote voiding and bladder care 4. Physical and mental support 5. Pain management 6. Amniotomy: artificial rupture of membranes.
Describe what bonding should look like during the postpartum period (4)
1. Skin-to-skin contact with the newborn 2. Looking them in the eyes (this is called en face position) 3. Responding to their needs 4. Engrossment (becoming very focused on the infant and their needs).
What are the seven theories to explain the onset of labor?
1. The uterine muscle stretches from the increasing size of the fetus, which results in the release of prostaglandins. 2. The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary. 3. Oxytocin stimulation works together with prostaglandins to initiate contractions. 4. Changes in the ratio of estrogen to progesterone occurs, increasing the ratio of estrogen. This is interpreted as progesterone withdrawal. 5. The placenta reaches a set age, which triggers contractions. 6. Rising fetal cortisol levels decrease progesterone formation and increase prostaglandin formation. 7. The fetal membrane begins to produce prostaglandins, which stimulate contractions. **All of these happen, but no one in particular triggers labor.
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?
10:30 a.m. Rationale: Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns.
For how long after childbirth does the postpartum period last?
6 weeks
While performing an assessment on a patient in labor, the nurse notes an abnormally contoured abdomen. What problems does the nurse suspect? (2) What should be done to correct this? (2)
A full bladder, which can make it harder for the fetus to pass through. Constipation/stool in bowels can also cause this, for which a stool softener is recommended. -Because an epidural can make it so that the client can't feel their bladder, a foley catheter may be needed.
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data?
A urine dipstick test to check for protein. Rationale: Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia.
What are accelerations in relation to FHR?
Acceleration is a visually apparent abrupt change in FHR above the baseline rate. The increase is >15 bpm and lasts 15 seconds or more, but returns to the baseline less than two minutes from the beginning of the acceleration. Most of the time these occur when there is fetal activity = good sign.
What is an ectopic pregnancy?
Any pregnancy that attaches outside of the uterine cavity. Usually not viable. Most commonly occurs in the fallopian tubes, but can also rarely occur in the intestinal or abdominal wall.
What kinds of psychological factors can impede the labor process? How should the nurse correct them?
Apprehension, screaming, and anxiety can interfere with pushing. Recommend breathing techniques.
While delivering a baby, the labor nurse observes green, meconium-stained amniotic fluid. What is the priority concern for the fetus?
Aspiration.
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
Assess and massage the fundus.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?
Assess fetal heart sounds.
A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?
Calcium gluconate Rationale: The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?
Continue to monitor the woman's temperature every 4 hours; this finding is normal. Rationale: A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor.
What is fetal presentation? What are the types? (3)
Denotes the body part that will first contact the cervix or be born first. Types: 1. Cephalic (96% of births) 2. Breech (4% of births) 3. Shoulder (<1% of births): puts parent and child in jeopardy unless skilled healthcare personnel can complete a cesarean birth.
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?
Docusate Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
Headache following anesthesia
What do doulas and labor coaches do?
Help moms visualize and relax throughout contractions. Not a midwife, but gives support, back rubs, and acts as a liaison for medical jargon.
What are the retrogressive maternal changes that occur during the postpartum period?
Involution of uterus and vagina: they need to shrink back down to pre-labor size.
When might the nurse suspect that there is a problem with attachment to a newborn?
If the parent doesn't want to hold the infant or look at them in the eyes, or criticizes the infant's appearance or gender, this could indicate a problem. However, it is important to take the client's culture into consideration. It is not always the male's role in certain cultures to immediately bond with the infant.
What is placenta previa?
It is a condition in which the placenta develops over and covers the cervix. -Can cause abnormal bleeding. -Makes vaginal delivery more difficult, so c-section is typical for these pregnancies.
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?
Just before birth.
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
Left lower quadrant. Rationale: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
A client in labor has been given an epidural anesthetic. Which nursing assessment is most important immediately following the administration of epidural anesthesia?
Maternal blood pressure. Rationale: As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, decreased beat-to-beat variability, and fetal bradycardia.
What is fetal skull molding? What causes molding during labor?
Molding is when the fontanelle spaces compress during birth, causing the skull bones to overlap along suture lines. It is caused by the force of uterine contractions as the vertex of the head is pressed against the not-yet-dilated cervix.
Regional Anesthetics for Labor -Pros (2) -Cons (1)
Pros: 1. Completely eliminate pain in localized area (like the vagina) while allowing patient to be awake and aware. 2. Does not depress uterine tone, which helps to prevent postpartum hemorrhage. Cons: 1. Can result in fetal bradycardia.
Opioid (Narcotic) Analgesics for Labor -Pros (1) -Cons (4)
Pros: 1. Potent effect Cons: 1. Can cause respiratory depression and fetal CNS depression. 2. Can slow labor if given too early 3. Can cause nausea and vomiting 4. Newborn needs careful assessment for 4 hours after birth.
Epidural Anesthesia for Labor -Pros (3) -Cons (3)
Pros: 1. Suitable for almost all patients. 2. Makes labor virtually pain-free, thus reducing stress. 3. Little to no effect on fetus, since it is not systemic. Cons: 1. Can cause hypotension. 2. Bearing down reflex may be reduced or absent, making it difficult to push. 3. In rare instances, can enter blood circulation instead of epidural space.
Nitrous Oxide (Laughing Gas) for Labor -Pros (3) -Cons (1)
Pros: 1. Recent studies have found that, in appropriate doses, it is safe for all during birth. 2. Does not affect pattern or intensity of contractions or interfere with normal labor. 3. Metabolized before it reaches the baby Cons: 1. Resulted in adverse neonatal outcomes in the past (before proper dosing and administration).
What is abruptio placentae?
The premature separation of the placenta which leads to hemorrhage. It is the most frequent cause of perinatal death.
Fetal Lie -How are they classified? (3) -Which is most common?
The relationship of the long axis of the mother to the long axis of the fetus. It can be longitudinal, transverse (perpendicular), or oblique (diagonal). -96% of fetuses lie in longitudinal (their long axis is equal to the long axis of the mother). -Longitudinal lies are further classified as cephalic or breech.
What is station, is regards to labor?
The relationship of the presenting part of the fetus to the level of the ischial spines. The fetus's descent from the uterus to birth.
What is fetal engagement?
The settling of the presenting part of the fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding?
The urinary output is normal.
A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?
The uterus becomes globular
What causes prolonged contractions, and when do they become a concern?
Uterine contractions should become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter, this could indicate uterine exhaustion. -Contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being, because this interferes with adequate uterine artery filling.
A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?
Uterine rupture
What is a prolapsed umbilical cord? Why is it a medical emergency? (2)
When the umbilical cord presents first and gets squeezed between the vaginal wall and the baby's head. Medical emergency because: -Baby is usually in breech presentation -They're usually pinching the cord, which is an oxygenation risk.
Which assessment finding is most important as labor progresses?
Whether the uterus relaxes completely between contractions. Rationale: It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur.
What are the psychological risks of going through labor without adequate emotional support?
Woman without adequate support can have a labor experience so frightening and stressful that they develop PTSD. **Non-English-speaking women are especially at risk of traumatic birth, so getting a translator is important.
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier.
