INTRAPARTUM

4.Fear of losing control -Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question.

GoNextStopBookmarkRationaleStrategyReference(s)Submit The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1.Exhaustion 2.Valsalva maneuver 3.Involuntary grunting 4.Fear of losing control

4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute. Maternal hypotension results in decreased placental perfusion, so the focus of nursing care would be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, so option 1 can be eliminated. Option 2 can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Option 3 can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2.Administer a tocolytic. 3.Administer an opioid antagonist. 4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute.

. Administer oxygen via face mask. -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.

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.

3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." -Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for three to five contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of the medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. Options 1, 2, and 4 are incorrect information about the medication effects.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1."The medication will only affect you and your pain level when given during a contraction." 2."The medication will provide the most optimal relief when it is given while your pain level is highest." 3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4."You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. -Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. Additionally, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the central nervous system and causing a seizure.

The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.

1.Assess for signs and symptoms of labor. -As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A non-stress test may be done, but not every 4 hours.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? 1.Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a non-stress test every 4 hours to assess fetal well-being.

1.Palpate the bladder at frequent intervals. The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Hypotension, not hypertension, is a concern. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider (HCP) has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed? 1.Palpate the bladder at frequent intervals. 2.Encourage the woman to walk to progress the labor. 3.Assess the blood pressure frequently for hypertension. 4.Encourage the woman to assume a supine position after the epidural has been placed.

1.Hematuria 2.Prolonged clotting times 5.Petechiae, oozing from injection sites, and hematuria

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation. Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1.Hematuria 2.Prolonged clotting times 3.Increased platelet count 4.Swelling of the calf of one leg 5.Petechiae, oozing from injection sites, and hematuria

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age.

2.The passage of meconium Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

A nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1.Maternal fatigue 2.The passage of meconium 3.Coordinated uterine contractions 4.Progressive changes in the cervix

3.Butorphanol tartrate - Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1.Fentanyl 2.Morphine sulfate 3.Butorphanol tartrate 4.Meperidine hydrochloride (Demerol)

1.Station 2.Dilation 3.Effacement The vaginal examination for a client in labor specifically determines effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply. 1.Station 2.Dilation 3.Effacement 4.Bloody show 5.Contraction effort

4.Administer oxygen at 8 to 10 L/min via face mask. Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. The IV infusion should be increased not decreased so as to increase the maternal blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1.Slow the intravenous (IV) rate. 2.Continue the oxytocin (Pitocin) drip. 3.Place the client in a high Fowler's position. 4.Administer oxygen at 8 to 10 L/min via face mask.

4.Document the findings and continue to monitor fetal patterns. -Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1.Contact the health care provider. 2.Place the mother in a Trendelenburg position. 3.Administer oxygen to the client by face mask. 4.Document the findings and continue to monitor fetal patterns.

4.Postpartum infection -Anemic women have a greater likelihood of : -cardiac decompensation during labor, -postpartum infection, and -poor wound healing.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for throughout the client's labor? 1.Anxiety 2.Hemorrhage 3.Low self-esteem 4.Postpartum infection

4.Pale straw-colored, with flecks of vernix -Amniotic fluid normally is pale straw-colored and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1.Light green, with no odor 2.Clear and dark amber-colored 3.Thick and white, with no odor 4.Pale straw-colored, with flecks of vernix

3.Increase in fundal height -increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. -Heavy vaginal bleeding, early deceleration on the fetal heart monitor, and back pain are not specific signs of concealed bleeding.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding? 1.Back pain 2.Heavy vaginal bleeding 3.Increase in fundal height 4.Early deceleration on the fetal heart monitor

1.Delivery of the fetus The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? 1.Delivery of the fetus 2.Strict monitoring of intake and output 3.Complete bed rest for the remainder of the pregnancy 4.The need for weekly monitoring of coagulation studies until the time of delivery

2.Periodic, early decelerations and indicative of fetal head compression -An early deceleration is described as a visually apparent gradual decrease of the fetal heart rate with a gradual return to the FHR baseline. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described, so therefore eliminate option 3.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations? 1.Episodic, late decelerations that indicate uteroplacental insufficiency 2.Periodic, early decelerations and indicative of fetal head compression 3.Periodic, variable decelerations and an indication of cord compression 4.Episodic, early decelerations that may be a result of maternal hypotension

2.Short-term variability present Reassuring signs in the fetal heart tracing include: - FHR of 120 to 160 beats/min, -accelerations of the FHR, -no variable decelerations, and the presence of - short-term variability. The short-term variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations would indicate cord compression.

The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved? 1.No accelerations of FHR 2.Short-term variability present 3.Variable decelerations present 4.Fetal heart rate (FHR) of 170 to 180 beats/min

3.Breathe rapidly.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1.Bear down. 2.Hold her breath. 3.Breathe rapidly. 4.Push with each contraction.

3.The cervix is dilated completely. - The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

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.

1.Uterine tenderness 2.Acute abdominal pain 3.A hard, "board-like" abdomen 5.Increased uterine resting tone on fetal monitoring In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1.Uterine tenderness 2.Acute abdominal pain 3.A hard, "board-like" abdomen 4.Painless, bright red vaginal bleeding 5.Increased uterine resting tone on fetal monitoring

2.Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the health care provider stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2.Discontinue the infusion of oxytocin (Pitocin). 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.

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.

1. Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3.Check the client for bladder distention. 4.Place the client in a side-lying position.

1.Provide pain relief measures. -for hypertonic and -for hypotonic will be amniotomy and pit

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin (Pitocin) infusion closely.

4.Painless vaginal bleeding -The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. - abruptio placentae.- Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted? 1.Back pain 2.Abdominal pain 3.Painful vaginal bleeding 4.Painless vaginal bleeding

2.Assess the vagina and cervix with a gloved hand. -It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented so therefore option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1.Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.

4.Complaints of severe abdominal pain -Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus would indicate that the muscle is not contracting.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1.Chest pain 2.A rigid abdomen 3.A soft and boggy uterus 4.Complaints of severe abdominal pain

1.Forceps delivery -Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1.Forceps delivery 2.Schultz presentation 3.Hypotonic contractions 4.Weak bearing-down efforts

3.A gravida II who has just been diagnosed with dead fetus syndrome - In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1.A primigravida with mild preeclampsia 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida II who has just been diagnosed with dead fetus syndrome 4.A gravida IV who delivered 8 hours ago and has lost 500 mL of blood

4.Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims position. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action? 1.Sit the client in a high Fowler's position. 2.Call the pharmacy for a tocolytic medication. 3.Get intravenous (IV) therapy equipment and solution from the storage area. 4.Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

2.Oxytocin (Pitocin) infusion -Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. Options 1, 3, and 4 identify therapeutic measures for a client with hypertonic dysfunction.

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and would expect to note which prescribed treatment for this condition? 1.Increased hydration 2.Oxytocin (Pitocin) infusion 3.Administration of a tocolytic medication 4.Administration of a medication that will provide sedation