Labor and delivery

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply. 1. Contractions that increase in frequency 2. Contractions that lessen after resting 3. Increased blood-tinged, mucoid vaginal discharge 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation

A key indicator of true labor is the progressive effacement and dilation of the cervix (Option 5). Contractions in true labor are regular, and increase in frequency, duration, and intensity (Option 1). The pain may initially start in the lower back and radiate to the abdomen (Option 4). (Option 2) True labor contractions will not lessen or dissipate with comfort measures (eg, rest, position change, hydration) and may intensify with walking or activity. Braxton Hicks contractions are irregular contractions that occur throughout pregnancy, and they do not result in cervical change. Although usually mild, they can be increasingly painful and regular for short periods during the last weeks before birth. However, in contrast with true labor, Braxton Hicks contractions will typically lessen with comfort measures. (Option 3) Mucoid vaginal discharge that is blood-tinged or brownish (eg, bloody show) is a common finding in the days preceding onset of labor; however, it is not a definitive sign that true labor has started.

The nurse is admitting a pregnant client who is experiencing intense "back labor." The nurse suspects the fetus is in which position?

A laboring client may experience lower back pain with contractions, or "back labor," when the fetus is in the right occiput posterior (ROP) position. This variation of vertex presentation causes the fetal occiput to exert added pressure on the woman's sacrum during contractions. Positioning the woman on her hands and knees often helps decrease back pain and facilitates fetal rotation into an anterior position. (Option 2) This fetus is in the right occiput anterior (ROA) position, which is optimal for birth as it allows for rotation of the fetal head through the birth canal. (Option 3) This fetus is in the right occiput transverse (ROT) position. When the fetus remains in the OP or OT position, labor is often prolonged. Most fetuses in these positions will rotate spontaneously to the OA position during labor. Manual rotation may be attempted with persistent OP or OT position. (Option 4) Breech presentation, with the fetal feet or buttocks presenting first in the maternal pelvis, does not cause back labor. Potential complications from breech presentation include ineffective dilation of the cervix and increased risk of umbilical cord prolapse.

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia(21%) 2. Hydrotherapy(29%) 3. IV narcotics(15%) 4. Pudendal nerve block(32%)

A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor (Option 4). In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration repair. (Option 1) An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes). (Option 2) Some clients forgo pharmacological pain relief during labor and instead utilize nonpharmacological techniques (eg, hydrotherapy, relaxation breathing). However, this client specifically requests pain relief, and nonpharmacological techniques would likely be ineffective considering birth is imminent. (Option 3) IV narcotics cross the placenta and can cause neonatal respiratory depression when administered close to birth. Therefore, these are not generally administered in the second stage of labor.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations(16%) 2. Inversion of the uterus(16%) 3. Uterine atony(27%) 4. Vaginal hematoma(40%)

A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option 1) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option 2) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option 3) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding.

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication(21%) 2. Give the medication slowly during the peak of the next contraction(50%) 3. Hold until contractions are occurring at least every 4 minutes for an hour(19%) 4. Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication(9%)

Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth (Option 2). Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief. (Option 1) There is no reason to discontinue oxytocin prior to IV administration of pain medication. However, IV push medications should not be given through IV lines already infusing medication. (Option 3) Narcotics do not typically inhibit contraction patterns or labor progress when labor is well established (ie, contractions every 2-5 minutes). However, it is inappropriate to withhold pain medication simply because the frequency of contractions is inadequate. For some clients, IV narcotics are used to provide pain relief and promote rest when latent labor is prolonged. (Option 4) Narcotics given by IV push may be diluted according to manufacturer directions so that they can be more easily pushed over the recommended administration interval. Diluent should never be obtained from the IV bag or tubing due to the risk of inadvertently adding medication to IV fluids.

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply. 1. Avoid discussing the adoption details until after the birth 2. Encourage the birth mother to hold the newborn 3. Notify other staff who may interact with the client of the adoption plan 4. Offer the birth mother a chance to say goodbye to the newborn 5. Use phrases that illustrate adoption as a decision of love, not abandonment

Adoption, the decision to relinquish care of a child to another, is complex and involves a variety of emotional and psychosocial responses from clients. The nurse should encourage the birth mother to create memories with her newborn to facilitate the grieving process. This may include holding the newborn, taking pictures, and naming the newborn (Option 2). When the time comes, offering the client a chance to say goodbye to the newborn supports the birth mother in her emotional transition and acknowledges the importance of her relationship with the newborn (Option 4). The nurse protects the client by notifying relevant staff of the decision, which prevents unintended, potentially hurtful remarks (Option 3). Substituting phrases like "giving up" and "giving away" with "choosing adoption" reinforce adoption as a loving decision and not neglect or abandonment (Option 5). (Option 1) Avoiding discussion of adoption details until after the birth inhibits the nurse's ability to plan care that respects the birth mother's wishes for interaction with the newborn and/or involvement of the adoptive parents in the birth process. Acknowledging the adoption plan early in the plan of care encourages the client to express emotions and be involved in decision-making.

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply. 1. Assessing the fetal heart rate before and after the procedure 2. Checking the client's temperature every 2 hours 3. Informing the client she will feel a sharp pain during the procedure 4. Keeping the client in a supine position after the procedure 5. Noting the characteristics of the amniotic fluid

Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). (Option 3) As with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water," is painless. (Option 4) Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix.

The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider (HCP) places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately? Click the exhibit button for additional information. 1. Cervix is 8 cm dilated and 100% effaced, with fetal presenting part at +1 station(29%) 2. Contractions are every 3 minutes and 60-80 seconds each(17%) 3. Fetal heart rate baseline is 155/min with early decelerations and moderate variability(27%) 4. Uterine resting tone baseline has increased to 45 mm Hg and perineal pads are dry(24%)

An amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate for low amniotic fluid (eg, oligohydramnios, ruptured membranes) in the uterus. During labor, an amnioinfusion is indicated to relieve persistent, recurrent variable decelerations caused by umbilical cord compression. Uterine overdistension is a potential complication due to infusion of too much fluid. Therefore, the nurse should use an infusion pump to control the rate and amount of fluid, evaluate for fluid return frequently, and monitor uterine resting tone closely. If baseline uterine resting tone is elevated (normal: ≤20 mm Hg) and minimal to absent fluid return is noted, the nurse should pause the infusion and notify the health care provider immediately (Option 4). (Option 1) The client's cervical examination findings indicate appropriate labor progression and do not need to be reported immediately. (Option 2) The nurse does not need to immediately report normal contraction frequency (ie, every 2-3 min or 3-5 contractions/10 min) and duration (ie, 60-80 seconds), which are expected during active labor. (Option 3) A normal fetal heart rate baseline (ie, 110-160/min), early decelerations, and moderate variability signify the amnioinfusion's effectiveness and do not need to be reported immediately.

The graduate nurse (GN) is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene? 1. Begins to apply fundal pressure when the HCP applies traction to forceps(58%) 2. Drains the client's bladder using a catheter before the placement of forceps(20%) 3. Notes the exact time the forceps are applied on a card for documentation in the birth record(9%) 4. Palpates for contractions and notifies the HCP when they are present(11%)

An operative vaginal birth uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (eg, exhaustion, cardiac or cerebrovascular disease) or fetal (eg, abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option 1). (Option 2) To avoid bladder damage, the nurse should ensure that the client has an empty bladder (eg, catheterization) before the forceps are applied. (Option 3) Documentation should reflect birth events accurately for legal purposes and be done in a timely fashion. Birth events can happen quickly, but noting the time when forceps or a vacuum extractor is applied is essential. (Option 4) The nurse notifies the HCP when contractions are palpated so that downward/outward traction can be applied to the forceps or a vacuum extractor during the contraction, which helps facilitate the birth.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia(76%) 2. Fetal tachycardia with moderate variability(20%) 3. Increased anxiety and discomfort with contractions(1%) 4. Painful, strong contractions every 3-4 minutes(2%)

Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option 3) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option 4) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern.

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale(38%) 2. Document that the client appears to be experiencing minimal pain(1%) 3. Monitor for nonverbal signs of ineffective coping with labor(57%) 4. Recognize that the client's stoicism is ineffective coping with labor(2%)

Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally diverse clients) helps the nurse provide culturally sensitive labor support and pain management. Clients from Japaneseculture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option 3). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. (Option 1) Pain assessments using a numeric pain scale do not adequately assess coping during labor. Furthermore, the appropriate frequency of pain assessments varies and may be influenced by labor progress and the client's preferred pain-relief method. (Options 2 and 4) Stoicism and lack of outward expressions of pain do not indicate that the client is not experiencing pain, nor should they be misidentified as ineffective coping.

A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. Which of the following interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply. 1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 3. Prepare for amnioinfusion 4. Reposition the client to supine 5. Stop the oxytocin infusion

Late decelerations occur after the onset of a uterine contraction and continue beyond its end. The lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline. Late decelerations occur when fetal oxygenation is compromised (eg, uteroplacental insufficiency, uterine tachysystole, hypotension). Immediate steps to correct late decelerations include: Stopping oxytocin if it is being administered (Option 5) Repositioning the client to the left/right side Administering oxygen by face mask (Option 1) Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed (Option 2) If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery. (Option 3) Amnioinfusion is administered through an intrauterine pressure catheter to relieve variable decelerations, not late decelerations; variable decelerations are usually caused by cord compression secondary to loss of amniotic fluid (eg, after rupture of membranes, because of oligohydramnios). (Option 4) Supine positioning can obstruct blood flow to the placenta. The client should be placed in a side-lying position to promote placental perfusion. This action relieves compression of the aorta and inferior vena cava, which can affect cardiac output, cause hypotension, and decrease placental perfusion.

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use(14%) 2. Multipara at 9 cm dilation with an urge to push(9%) 3. Nullipara at 3 cm dilation desiring to ambulate(32%) 4. Nullipara at 7 cm dilation moaning with contractions(43%)

Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects. IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase (Option 4). (Option 1) Although this client is in active labor, recent heroin use is a contraindication to opioid agonist-antagonists because of the risk for maternal and/or fetal withdrawal symptoms. (Option 2) An urge to push may indicate imminent birth, especially in a multiparous client. To ensure newborn safety, imminent birth is a relative contraindication for the administration of narcotics. (Option 3) Opioid administration in latent labor may slow labor progression. In addition, medication adverse effects (eg, sedation, dizziness) are a safety concern for a client desiring to ambulate.

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply. 1. Abnormal or indeterminate fetal heart rate patterns 2. Delayed breast milk production 3. Placenta previa 4. Postpartum hemorrhage 5. Uterine tachysystole

Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions (Option 1). Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin (Option 4). Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. Uterine tachysystole (ie, >5 contractions in 10 minutes) (Option 5) (Option 2) Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production. (Option 3) Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa (ie, abnormal implantation of the placenta over the cervical os) is unrelated to oxytocin administration.

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain? 1. The client has a history of three previous cesarean births(13%) 2. The client has a signed consent form for a cesarean hysterectomy(24%) 3. The client has removed all metal jewelry and contact lenses(1%) 4. The client has two 18-gauge IVs and a blood type and crossmatch(60%)

Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary (Option 4). (Option 1) Previous cesarean birth is a risk factor for placenta accreta. Knowing the client's medical/surgical history is important but is not prioritized over the client's readiness for a blood transfusion. (Option 2) A hysterectomy during cesarean birth with the placenta left in place may be required to reduce blood loss. The client should understand the implications of the procedure (ie, no future childbearing), but this is not a priority over ensuring readiness for a potential blood transfusion. (Option 3) Metal and, occasionally, contact lenses should be removed prior to surgery to protect the client from injury, but this is not a priority over IV access and blood product availability.

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area(1%) 2. Gently pull on the cord(4%) 3. Keep the infant warm(57%) 4. Massage the fundus(36%)

Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled. (Option 1) The perineal area can be cleansed if needed once the placenta has been expelled. (Option 2) To avoid uterine inversion or cord avulsion (tearing or snapping), the nurse should not pull on the cord. Once placental separation occurs, signified by cord lengthening, a gush of blood, uterine cramping, and vaginal pressure, the mother can bear down gently to expel the placenta. (Option 4) Fundal massage is performed after expulsion of the placenta to increase uterine tone and decrease bleeding.

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift

Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1) Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2) Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4) Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained (Option 3) Artificial rupture of membranes (AROM), or amniotomy, is performed to augment labor or assess amniotic fluid in clients who are at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated. (Option 5) Clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion.

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option 5). (Option 3) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures.

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10(59%) 2. Firm and posterior cervix(10%) 3. History of precipitous labor(6%) 4. Reactive nonstress test(23%)

The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥6-8 usually indicates that induction will be successful (Option 1). (Option 2) A cervix that is firm and posterior is associated with a low Bishop score, which reflects a low likelihood of successful labor induction. (Option 3) A history of precipitous labor (<3 hours from onset of contractions to birth) may indicate that the client will again experience precipitous labor once labor is established. However, such a history is not an independent predictor of successful induction. (Option 4) A reactive nonstress test indicates that the fetus is well oxygenated and establishes fetal well-being. It does not provide information about the likely success or failure of labor induction.

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? 1. Administer prescribed IV meperidine for pain relief(0%) 2. Encourage client to bear down with spontaneous urges to push(12%) 3. Place client in the lithotomy position in preparation for birth(35%) 4. Provide encouragement and coaching in breathing techniques(51%)

The period of active labor from 8-10 cm dilation (ie, "transition") is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed during transition. Nursing priorities include providing emotional support and encouragement, and coaching the client in breathing techniques (Option 4). (Option 1) Meperidine (Demerol) is an opioid occasionally prescribed for analgesia during early labor. It has a rapid onset (5 minutes) when given IV, and a duration of 2-3 hours. However, it should be avoided within 1-4 hours of birth due to the potential for neonatal respiratory depression. (Option 2) The second stage of labor begins once complete dilation (10 cm) is achieved. Clients may feel the urge to push (Ferguson reflex) prior to complete dilation if the fetal head is low in the pelvis. However, pushing should be delayed until complete dilation is achieved to avoid cervical swelling and/or cervical lacerations. (Option 3) Although lithotomy positioning may be more convenient for the birth attendant, upright or lateral positions encourage fetal rotation and descent, increase client comfort, and decrease the risk of perineal trauma. This client has not yet reached complete dilation and should be allowed to move freely.

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action? Click on the exhibit button for additional information. 1. Apply oxygen 10 L/min face mask(9%) 2. Continue to monitor the client(52%) 3. Discontinue oxytocin infusion(31%) 4. Notify the health care provider (HCP)(6%)

This fetal heart rate strip shows 2 accelerations and moderate variability. An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a reassuring finding most often indicating fetal movement. Moderate variability refers to fluctuations in the baseline heart rate between 6-25/min. It is considered normal and indicates that the fetus is healthy and has adequate oxygenation and normal function of the autonomic nervous system. No immediate intervention is needed. (Options 1, 3, and 4) A non-reassuring heart rate pattern such as late or variable decelerations would require the need to stop oxytocin, apply oxygen, and notify the HCP.

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply. 1. "Do you feel like the contractions are getting stronger?" 2. "Does anything you do make the pain better?" 3. "Have you lost your mucous plug?" 4. "How frequent are the contractions?" 5. "Where do you feel the contraction pain most?"

True labor is defined as contractions that cause progressive cervical change over time. Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort measures in relieving the pain, and the location of the pain (Options 2 and 5). Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated with lower back discomfort that radiates to the abdomen are indicative of true labor (Options 1 and 4). If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and education about signs of labor and suggest comfort measures. Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and voiding often. (Option 3) During pregnancy, a collection of secretions forms a "mucous plug" in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor.

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first? Click on the exhibit button for additional information. 1. Administer IV fluid bolus(3%) 2. Assess for umbilical cord prolapse(46%) 3. Notify the health care provider(11%) 4. Reposition client to alternate side(37%)

Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord (Option 2). If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help. (Option 1) Although IV fluid bolus is part of intrauterine resuscitation, in the presence of prolonged deceleration after rupture of membranes, the first action is to rule out a prolapsed cord. (Option 3) The priority is to quickly identify a prolapsed cord and displace the presenting fetal part off the cord. Someone else should notify the health care provider while the nurse performs emergent interventions. (Option 4) A position change to the alternate side may help improve uteroplacental blood flow but will probably not displace the presenting part off a prolapsed cord. The knee-chest position is optimal but challenging with epidural anesthesia in place.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds(60%) 2. Contraction frequency of every 3 minutes(15%) 3. Contraction intensity of 45 mm Hg(8%) 4. Uterine resting tone of 10 mm Hg(15%)

Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. (Option 2) Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. (Option 3) In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus. (Option 4) Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus, ensuring a well-oxygenated fetus.

The nurse reviews the external fetal monitoring tracing of a client receiving an oxytocin infusion for labor augmentation. The health care provider (HCP) asks the nurse to increase the oxytocin infusion rate. Which action by the nurse is appropriate at this time? Click the exhibit button for additional information. 1. Ask the charge nurse to speak with the HCP(3%) 2. Increase the oxytocin infusion rate as requested by the HCP(17%) 3. Recommend to the HCP that the infusion rate be decreased at this time(48%) 4. Request that the current infusion rate be maintained due to the client's contraction pattern(30%)

Uterotonic drugs (eg, oxytocin) are prescribed to induce or augment labor by promoting uterine contractions. The nurse must administer oxytocin via infusion pump and implement continuous electronic fetal monitoring during therapy because oxytocin is a high-alert medication. Most oxytocin administration protocols dictate gradual titration to achieve a contraction frequency of every 2-3 minutes. Uterine tachysystole (ie, >5 contractions in 10 min) is a potential adverse effect of oxytocin that can decrease placental blood flow and compromise fetal oxygenation. Treatment includes decreasing or stopping the oxytocin infusion and, potentially, administering an IV fluid bolus and/or tocolytic drugs (eg, terbutaline) (Option 3). (Option 1) First, the nurse should independently communicate concerns to the health care provider (HCP). If the HCP disagrees with the nurse's assessment, the charge nurse can then assist with communication. (Option 2) The tracing shows 6 contractions in 10 minutes. Implementing the HCP's request without further clarification puts the client at risk. (Option 4) Although the fetal heart rate (FHR) is normal in the tracing, continued exposure to the current dose of oxytocin may lead to FHR decelerations. Requesting to keep the infusion rate unchanged is a failure to intervene; the appropriate intervention for uterine tachysystole is to decrease or stop the infusion.