Intrapartum Period

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care?

Monitor of intake and output.

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?

Prepare the client and partner for a cesarean birth as soon as possible.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids. Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.

A nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply.

alkaline pH of fluid when tested with nitrazine paper presence of amniotic fluid in the vagina fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry

A 30-year-old multigravida pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when she says that an electronic monitor performs which function?

ensures a more comfortable atmosphere for the client and labor

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

offering support by reviewing the short-pant form of breathing

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?

respiratory distress syndrome

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response?

the nurse's most appropriate response? "Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" What should be the nurse's first action?

Inspect the perineum.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?

The cord lengthens outside the vagina.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?

Instruct the partner on touch, massage, and breathing patterns.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion.

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion?

fetal heart rate variability within 5 to 10 beats/minute

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do?

Ask the client to sign the consent form.

A client at 28 weeks' gestation is admitted in preterm labor. An IV infusion loading dose of 4 g magnesium sulfate is started IV piggyback at a rate of 300 mL/min. After 15 minutes, the nurse assesses the client's deep tendon reflexes and finds them hyporeflexive. What is the nurse's priority intervention?

Stop the magnesium sulfate infusion.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding?

evidence of spontaneous rupture of the membranes

The nurse is caring for a postpartum client with an episiotomy. The nurse assesses the client closely for what complication that the client is at greatest risk of developing?

infection

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition?

prolapsed cord

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse

The nurse is working on a hospital's birthing unit when a primigravid client in active labor is to receive morphine. As the nurse enters the medication room, the nurse observes a coworker slipping a vial of morphine into the side pocket of the uniform. Which action would be mostappropriate?

Notify the supervisor of the unit. When a nurse observes the theft of a narcotic, it is the responsibility of the nurse to report the incident to the supervisor of the unit. The supervisor of the unit can confront the co-worker and notify the hospital's chief of security about the incident. In some situations, the drug-abusing co-worker may be offered drug counseling. In situations where the drugs are being sold, the police should be notified.The nurse should not confront the co-worker, because this may put the nurse in danger.It is not the responsibility of the nurse to notify police about this incident.

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position?

posterior

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

chaplain, because his educational background includes strategies for handling grief The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?

Notify the physician that the partner has been waiting to discuss the mother's condition. Because of the client's severe and deteriorating condition, the nurse is obligated to advocate for the family and to notify the physician of the partner's request for a meeting and information. It is not appropriate to tell a client or family not to worry or that the physician is too busy to come. While it may be appropriate to inquire about family supports, in this context it is crucial that the nurse respond to the client and partner's concerns. The nurse should ensure their practice aligns with the American Nurses Association (Canadian Nurses' Association) Code of Ethics, ensuring that the nurse is advocating for the family and promoting and respecting informed decision making.

The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2°F (38.4°C). Examination indicates that the client is leaking amniotic fluid. What is the nurse's priority concern based on these findings?

intrauterine infection

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next?

Reposition the client and continue to evaluate the tracing.

A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse?

"Changes in your blood pressure can affect the fetus."

The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply.

oxygen administration maternal position change IV hydration

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?

Hold the breath throughout the length of the contraction.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission?

Assess the imminence of birth.

The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first?

Prepare an area to receive the neonate.

A client had a cesarean section with her first pregnancy and is hoping to have a vaginal birth with this pregnancy. She begins to cry at her 38-week visit when she realizes that her baby is a breech presentation. She says, "I just know it's going to be horrible again. I won't be able to breastfeed my baby. It will be painful." What response from the nurse is appropriate?

"Tell me about your previous baby's birth."

An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored?-=-=--------

Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first?

Complete a vaginal examination.

The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do?

Continue to monitor the client and fetus.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?

Maintain a patent airway. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the mostappropriate nursing action at this time?

Prepare the client for an assisted or cesarean birth.

A nurse needs to obtain a good monitor tracing on a client in labor The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first?

Reposition the client to her left side. This client is hypotensive because of decreased blood flow through the aorta. By turning the client to her left side, the nurse removes the weight of the uterus from the aorta and increases the maternal blood flow. Taking blood pressure, summoning the physician, starting oxygen, and increasing I.V. fluids aren't necessary unless repositioning doesn't relieve the symptoms.

What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply.

assigning the Apgar scores drying the newborn initiating skin to skin care taking newborn vital signs The second stage of labor ends with birth. Delivery of the placenta normally happens 5 to 30 minutes after birth. It is the nurse's responsibility to note the time of birth and complete or assist with the 1- and 5-minute Apgar scores. The infant should be dried immediately after birth to prevent heat loss from evaporation. Ideally, the infant is then placed skin to skin with the mother. Vital signs on the infant should be taken soon after birth. Oxytocin administration is done to actively manage the fourth stage of labor after the delivery of the placenta. Perineal repairs also happen after the delivery of the placenta. Add a Note

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem?

pain

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.