Labor & Delivery

At 28 weeks' gestation, a client is admitted in preterm labor. An I.V. infusion of magnesium sulfate is started. Which client outcome reflects the nurse's awareness of an adverse effect of magnesium sulfate? "The client remains free from polyuria." "The client remains free from hypertension." "The client remains free from hyporeflexia." "The client remains free from tachycardia."

"The client remains free from hyporeflexia"

A multigravid client who is 10 cm dilated is admitted to the labor and birth unit. In addition to supporting the client, priority nursing care includes: a) Increasing IV fluids. b) Turning on the infant warmer. c) Providing client education regarding care of the newborn. d) Determining the client's preferences for pain control.

B. Turning on the infant warmer. Nursing care for this client includes providing support, preparing for birth, assessing for potential complications, and providing for care of the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. Oxygen and IV fluids may be indicated if variable or late decelerations are noted on the fetal heart monitor, but decelerations are not indicated in the question. It is likely too late for pharmacologic pain relief for a multigravida. Client education regarding care of the newborn is not appropriate at this time.

A pregnant client's labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which of the following suggestions would be most helpful for the client's husband? a) "Keep a record of her contraction pattern." b) "Have her practice rapid, shallow breathing." c) "Suggest that she receive an epidural anesthetic." d) "Encourage her to rest between contractions."

D - Because the client has had prolonged labor, the client should be encouraged to rest as much as possible. In addition, the client should be encouraged to use appropriate breathing techniques, particularly slow chest breathing. Although the husband or significant other may keep track of the client's contraction pattern, this responsibility is that of the nurse caring for the client. Suggesting that she receive an epidural anesthetic is not appropriate because the client may desire natural childbirth methods. Rapid, shallow breathing or pant/blow breathing is inappropriate for this stage of labor because it can cause possible hyperventilation and lead to dizziness. This type of breathing is more appropriate for the transition stage of labor.

Low fowler's:

HOB 15-30 degrees

Semi-Fowler's Position

HOB 30-45 degrees

Standard Fowler's

HOB 45-60 degrees

A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? Assess a laboring client for a change in labor pattern. Perform a straight catheterization for protein analysis. Complete an initial assessment on a client. Increase the oxytocin rate on a laboring client

Perform a straight catheterization for protein analysis

Which statement describes the term fetal position? Fetal head or breech at cervical os Fetal posture Relationship of the fetus's presenting part to the mother's pelvis Relationship of the fetal long axis to the mother's long axis

Relationship of the fetus's presenting part to the mother's pelvis RATIONALES: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.

A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate? Inform the client and her partner that only fathers can stay in the birthing room. Encourage the partner to stay with the client because, as the baby's father, he is the best birth companion. Ask the client if she agrees with her partner's desire to stay in the waiting room. Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born.

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born.

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?

The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.

Fetal fibronectin: when get tested?

When you are 22 to 35 weeks pregnant and are having symptoms of premature labor; sometimes if you are at high risk, such as if you have had a previous preterm delivery or have a short cervix

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first: assess the client's temperature and pulse. document the color of the amniotic fluid. assess the fetal heart rate (FHR) for 1 full minute. monitor the client's contraction pattern.

assess the fetal heart rate for 1 full minute

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

check the fetal HR

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? client at 40 weeks' gestation whose fetus weighs 8 lb (3,630 g) by ultrasound estimate client at 37 weeks' gestation with fetus in ROP position client at 38 weeks' gestation with active herpes lesions client at 32 weeks' gestation with fetus in breech position

client at 38 weeks' gestation with active herpes lesions

The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention? a) The cervix is fully dilated. b) The client has not received anesthesia. c) The fetus is at 0 station. d) The membranes are intact.

d) The membranes are intact. Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at -1 station

primipara

first birth

para

number of births after 20 weeks

gravida

number of pregnancies

When administering magnesium sulfate to a client with preeclampsia , the nurse understands that this drug is given to:

prevent seizures

Fetal fibronectin test: why get tested?

to help evaluate a woman's risk of preterm delivery

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? a) placement of bloody sheets in a container designated for contaminated linens b) use of protective goggles during a cesarean birth c) disposal of used scalpel blades in a puncture-resistant container d) wearing of sterile gloves to bathe a neonate at 2 hours of age

wearing of sterile gloves to bathe a neonate at 2 hours of age Correct Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate.

After explaining about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "My membranes are likely to have a foul odor." "My contractions are going to be less painful." "I am going to have a higher blood pressure." "I should try to push with each contraction."

"I should try to push with each contraction." - The second stage of labor begins with complete cervical dilation and ends with childbirth. During this time, the client is encouraged to push with each contraction. Throughout labor, the client's blood pressure should remain within normal limits. The membranes often rupture in the second stage of labor, but they also may rupture earlier—in some instances, even before labor begins. However, the fluid should not have a foul odor, which is indicative of an infectious process. Contractions can be strong and painful in the first stage of labor as well as the second stage.

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict? "I will make every effort to work with your cultural beliefs." "Your attitude toward the male physician could put the baby at risk." "Clients cannot always be guaranteed there will be a female physician on call." "Please try to understand that the physician is a professional and will be escorted by a female nurse."

"I will make every effort to work with your cultural beliefs." Explanation: The nurse knows he/she must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by health care providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.

A client hospitalized for preterm labor tells the nurse her mother in law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse? "Your mother in law was wrong. You didn't do anything to cause this." "Let's talk about how preterm labor occurs, so as to help you understand what causes it." "It is natural to blame one another when things become difficult." "Did you think that you did anything you shouldn't have?"

"Let's talk about how preterm labor occurs, so as to help you understand what causes it." Explanation: The nurse needs to explore the client's feelings to assist her in understanding what happened and to disperse the blame she is feeling. The other responses do not explore feelings experienced by the client and may stop the dialogue with the nurse from continuing.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." "I'll insert a urinary catheter; then you won't need to get out of bed."

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Do you have any allergies?" "Do you have any chronic illnesses?" "Who will be with you during labor?" "What is your expected due date?

"What is your expected due date?" RATIONALES: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.

five digit system

-GTPAL -Gravidity (G)- the total number of pregnancies (without reference to the number of fetuses) the woman has had (including current) -Term (T)- full term pregnancies (37-40 weeks) -Preterm (P)- pre-term deliveries (20-36 weeks) -Abortions (A)- signifies whether the woman has had any abortions or miscarriages before the period of viability (20 weeks) -Living Children (L)- number of living children -The five digit system utilizes these 5 letters to summarize a woman's obstetric history -Ex. If a woman is pregnant for the fourth time and her previous pregnancies yielded one full term neonate, premature twins, and one abortion at 19 weeks, and now has three living children, she is designated as 4-1-1-1-3

What data indicates to the nurse that placental detachment is occurring? a) An abrupt lengthening of the cord b) Decreased vaginal bleeding c) A decrease in the number of contractions d) Relaxation of the uterus

A

Cephalic position

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first

After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which occurs?

A sudden gush of dark blood occurs. Explanation: A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and changing of the uterus to a round or spherical shape are impending signs of placental separation. Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion

The nurse is caring for a client in labor who has tested positive for gonorrhea. Which of the following will the nurse include in the client's plan of care?

Administer erythromycin eye drops to the infant after birth

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes Allowing the client to ambulate as tolerated Helping the client use breathing exercises to manage her contractions Carefully titrating the oxytocin based on the client's pattern of labor

Allowing the client to ambulate as tolerated

Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? Blood pressure decreases at the peak of each contraction. Blood pressure decreases as a sign of maternal pain. Decreased blood pressure is the first sign of preeclampsia. Alterations in cardiovascular function affect the fetus.

Alterations in cardiovascular function affect the fetus.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

An increased sense of rectal pressure

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? A decrease in intensity of contractions An increase in fetal heart rate variability An increased sense of rectal pressure Episodes of nausea and vomiting

An increased sense of rectal pressure

A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: 1. uterine inversion. 2. uterine atony. 3. uterine involution. 4. uterine discomfort.

Answer: 2 RATIONALES: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? 1. Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. 2. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. 3. Notify the physician and security immediately. 4. Ask the nursing assistant to dispose of the marijuana that the client can't smoke anymore.

Answer: 3 RATIONALES: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security who are specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.

When caring for a client with preeclampsia, which action is a priority? 1. Monitoring the client's labor carefully and preparing for a fast delivery 2. Continually assessing the fetal tracing for signs of fetal distress 3. Checking vital signs every 15 minutes to watch for increasing blood pressure 4. Reducing visual and auditory stimulation

Answer: 4 RATIONALES: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.

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. Who should the nurse manager consult to help the staff cope with this unexpected death? 1. The human resource director, so she can arrange vacation time for the staff 2. The physician, so he can provide education about HELLP syndrome 3. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff 4. The chaplain, because his educational background includes strategies for handling grief

Answer: 4 RATIONALES: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation 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.

amniotomy

Artificial rupture of membranes (AROM), also known as an amniotomy, may be performed by a midwife or obstetrician to induce or accelerate labor. The membranes may be ruptured using a specialized tool, such as an amnihook or amnicot, or they may be ruptured by the proceduralist's finger.

A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which of the following would be a priority intervention by the nurse to establish whether the client can have an epidural? Call a consult with anesthesia for an epidural. Measure the intensity of her contractions. Assess cervical dilation. Assess her response to intravenous morphine.

Assess cervical dilation.

A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The health care provider (HCP) has ordered prostaglandin E2 gel for the client. Before administering prostaglandin E2 gel to the client, which action should the nurse do first? Assess the frequency of uterine contractions. Place the client in a side-lying position. Prepare the client for an amniotomy. Determine whether the membranes have ruptured.

Assess the frequency of uterine contractions

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? Review the client's obstetrical history. Assess the client's coping skills in labor. Ensure that the client will have a support person in labor. Assess the imminence of birth.

Assess the imminence of birth

A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform? Begin continuous fetal heart rate monitoring. Administer oxygen via nasal cannula at 4 L/min. Change the client to the left lateral position. Inform the physician that birth is imminent.

Begin continuous fetal heart rate monitoring. Explanation: Meconium staining in the amniotic fluid is not always a sign of fetal distress but is correlated with its occurrence. It reveals that the fetus has had an episode of loss of sphincter control. This clinical situation requires further investigation with fetal heart rate monitoring. There is no indication that birth is imminent. Changing the client to left lateral position may enhance uteroplacental exchange, allowing more oxygen to reach the fetus; however, it is most critical to assess the fetal heart rate, as this provides immediate information surrounding the health and safety of the fetus.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: prepare for birth. complete a vaginal examination to determine dilation, effacement, and station. have naloxone hydrochloride available in the birthing room. document the client's relief due to pain medication.

Complete a vaginal examination to determine dilation, effacement, and station

Question 5 See full question 4m A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which of the following should be the nurse's next action?

Continue to monitor BP

The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction? Call the anesthesiologist to begin administration of epidural anesthesia. Administer a 500 mL bolus of intravenous fluid to prevent hypotension. Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. Insert an indwelling urinary catheter to determine intake and output accurately.

Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. Explanation: Induction of labor with an oxytocic agent carries risks, such as water intoxication and uterine rupture. Before beginning intravenous oxytocin infusion, the nurse should obtain a baseline measurement of fetal heart rate and assess the client's contractions. If the fetal heart rate pattern shows fetal distress, the client is not a candidate for induction. This monitoring continues throughout the duration of therapy. The infusion should be discontinued and the primary care provider notified if fetal distress is noted or if contractions occur less than 2 minutes apart or last longer than 60 seconds.

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 he/she is allowed to perform this skill. What is the nurse's most appropriate response? a) "No, only certified registered nurses can perform this skill." b) "Yes, but only after you read about the procedure in the regional policy and procedure manual." c) "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." d) "Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

D

A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? Document findings on the client's chart, and continue to monitor labor progress. Perform vaginal exam to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean section. Position the client on her left side, and administer O2 via face mask.

Document findings on the woman's medical record, and continue to monitor labor progress. Explanation: The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean section.

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? Late decelerations Persistent fetal bradycardia Variable decelerations and sinusoidal pattern Fetal heart rate variability within 5 to 10 beats/minute

Fetal heart rate variability within 5 to 10 beats/minute

High Fowler's

HOB 60-90 degrees

Fetal distress:

HR below 110 or above 160, shows decreased or no variability, and is hyperactive or no activity Fetal distress is an emergency pregnancy, labor, and delivery complication in which a baby experiences oxygen deprivation (birth asphyxia), causing changes in the baby's heart rate, decreased fetal movement, and abnormal substances in the amniotic fluid.

Initial client assessment information includes: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints? Headache, blurred vision, and facial and extremity swelling Abdominal pain, urinary frequency, and pedal edema Diaphoresis, nystagmus, and dizziness Lethargy, chest pain, and shortness of breath

Headache, blurred vision, and facial and extremity swelling

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe? intravenous penicillin intravenous gentamicin sulfate intramuscular cefaclor intramuscular betamethasone

IV penicillin

ROP

In Right Occiput Posterior (ROP), baby is head down and the back is to the side- the right side. This position can be deceptively reassuring. ROP is the most common of the four posterior positions. Right Occiput Posterior - Baby's back favors mother's right and the back of baby's head is towards mother's posterior.

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? Teach the client and her partner about pain transmission. Teach the client progressive muscle relaxation. Instruct the partner on touch, massage, and breathing patterns. Use hypnosis on the client and her partner.

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

The primary health care provider orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?

Lecithin-sphingomyelin (L/S ratio).

The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant woman performs which of the following actions?

Leopold's maneuvers

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? Fetal tachycardia Maternal hypotension Maternal oliguria Maternal tachycardia

Maternal hypotension- a common physiological effect of epidural and spinal anesthesia is hypotension, primarily due to the blockade and the SNS causing arterial and venous vasodilation with subsequent "functional" hypovolemia

Breech birth

Most babies will move into delivery position a few weeks prior to birth, with the head moving closer to the birth canal. When this fails to happen, the baby's buttocks and/or feet will be positioned to be delivered first. This is referred to as "breech presentation."

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first? a) Prepare the client for imminent birth. b) Note the color, amount, and odor of the amniotic fluid. c) Auscultate the client's blood pressure. d) Perform a vaginal examination to determine dilation.

Note the color, amount, and odor of the amniotic fluid.

A client who has abruptio placentae exhibits cyanosis in her earlobes, capillary filling time >3 seconds, and reports "heartburn." Which of the following is the best nursing intervention? Assess for vaginal bleeding. Elevate the head of the bed. Notify the healthcare provider immediately. Increase the temperature of the room and provide warmed blankets.

Notify the healthcare provider immediately. Explanation: The manifestations of earlobe cyanosis, capillary filling time >3 seconds, and gastric distress in this client may indicate disseminated intravascular coagulation. The healthcare provider should be notified immediately . Increasing the ambient temperature may increase client comfort, and an assessment of vaginal bleeding is indicated. Sitting the client up in bed is not indicated.

A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which breathing technique? a) deep chest breathing b) rapid pant-blow breathing c) slow abdominal breathing d) rapid, shallow chest breathing

Rapid, shallow chest breathing The psychoprophylaxis method of childbirth suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70 breaths/min. Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to: remain in a side-lying position with the head elevated. request local anesthesia for vaginal birth. breathe slowly after each contraction. avoid the use of analgesics for the labor pain.

Remain in a side-lying position with the head elevated. Explanation: The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.

33s The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess?

Shoulder dystocia

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The frequency of contractions The time of membrane rupture The color of the ruptured fluid The presence of fetal movement after the membranes ruptured

The time of membrane rupture

A physician placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? The maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR Time of fetal scalp electrode placement, name of the physician who placed the electrode, and frequency of uterine contractions The name of the physician who applied the electrode, Doppler transducer placement, and FHR Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR)

Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR)

A gravida 3 para 1 laboring client is 9 cm dilated and is changing position frequently to cope with the intensity of the contractions. The client's husband has gone to the cafeteria to take a break. The client tells the nurse that she is tired but is afraid of being left alone and that her husband will miss the birth. Which of the following is the nurse's most appropriate action? Use the call bell to ask another nurse if he/she can help locate the client's husband. Tell the client not to worry because the birth likely won't happen for another 4-5 hours. Return to the nurse's station to phone the physician because birth is imminent. Tell the client that he/she will have someone try to find her husband.

Use the call bell to ask another nurse if he/she can help locate the client's husband

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? placenta head umbilical cord chest

Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.

Which fetal presentation is most favorable for birth? Transverse lie Frank breech presentation Vertex presentation Posterior position of the fetal head

Vertex presentation

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor? When the client is 2 hours postpartum When the placenta has been birthed When the client is fully dilated and effaced When the neonate has been born

When the placenta has been birthed RATIONALES: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the baby. The fourth stage of labor includes the first 4 hours after birth.

fetal fibronectin

a fibronectin protein produced by fetal cells. It is found at the interface of the chorion and the decidua (between the fetal sac and the uterine lining). It can be thought of as an adhesive or "biological glue" that binds the fetal sac to the uterine lining.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about the contractions? A) Duration, frequency, and intensity B) Duration, dilation,, frequency C) Frequency, duration maternal position D) Duration, effacement, position

a) Duration, frequency & intensity

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? a)beginning of one contraction to the beginning of the next contraction b) end of one contraction to the end of the next contraction c ) beginning of one contraction to the end of the next contraction d) acme of one contraction to the beginning of the next contraction

a) beginning of one contraction to the beginning of the next contraction

A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse understands that which condition is a contraindication to hydrotherapy? a. ruptured membranes b. multifetal gestation c. diabetes mellitus d. hypotonic labor patterns

a. ruptured membranes

At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?

altered tissue perfusion related to effects of anesthesia

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first: assess the client's temperature and pulse. document the color of the amniotic fluid. monitor the client's contraction pattern. assess the fetal heart rate (FHR) for 1 full minute.

assess the fetal heart rate (FHR) for 1 full minute.

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for which of the following reasons? a) To destroy fetal Rh-positive cells during the next pregnancy. b) To prevent Rh-positive sensitization with the next pregnancy. c) To provide active antibody protection for this pregnancy. d) To decrease the amount of Rh-negative sensitization for the next pregnancy.

b The purpose of the RHIG is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an Rh-positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. The RHIG does not cross the placenta and destroy fetal Rh-positive cells.

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? blood pressure cognitive function contraction pattern level of consciousness

blood pressure

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? Notify the health care provider (HCP). Turn the client to her left side. Turn off the oxytocin infusion. Increase the maintenance IV fluids.

c) Turn off the oxytocin infusion. The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? painful contractions every 3 to 5 minutes cervical dilation and effacement fetal descent into the pelvic inlet leaking amniotic fluid clear in color

cervical dilation and effacement

The primary care provider orders magnesium sulfate intravenously for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when: the client is sedated. contractions cease. there is improvement in fetal lung function. there is increased placental perfusion.

contractions cease.

The nurse in the labor and birth area receives a telephone call from the emergency department announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby is coming ... Help!" The fetal skull is crowning. The nurse should obtain which information first? estimated date of birth amniotic fluid status gravida and parity prenatal history

estimated date of birth

primigravid

first pregnancy

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief? right lateral hands and knees lithotomy tailor sitting

hands and knees Explanation: Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP position. Tailor sitting facilitates descent in OA positions.

A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for: uterine relaxation. hypotension. spinal headache. hyperreflexia.

hypotension

A client in the first stage of labor is being monitored using an external fetal monitor. A nurse notes variable decelerations on the monitoring strip. Into what position should the nurse assist the client?

lateral

Most commonly used drug to treat preterm labor:

magnesium sulfate; only given IV

A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. The nurse's next action should be to: document the findings of the nitrazine test. offer the client a sterile sanitary pad after performing perineal care. perform a sterile vaginal examination to assess the cervix. notify the HCP that the membranes are ruptured.

notify the HCP that the membranes are ruptured. Explanation: Nitrazine paper responds to alkaline fluids by changing blue; amniotic fluid is alkaline so the color verifies that the membranes are ruptured. The nurse notifies the provider that membranes are ruptured so that a plan of action can be developed. Rupture of membranes in the absence of labor increases the risk of infection. Vaginal examinations are limited until labor is initiated. Wearing a sanitary pad increases potential for infection. Documentation of the Nitrazine test is completed after notifying the provider.

abruptio placentae

premature separation of the placenta from the inner uterine wall (womb) before delivery. The condition can deprive baby of oxygen and nutrients. Symptoms include vaginal bleeding, belly pain, and back pain in the last 12 weeks of pregnancy. Depending on the degree of separation and how close the baby is to full-term, treatment may include bed rest or a C-section.

The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason?

to contract the mother's uterus