Maternal Child Chapter 11

A pregnant woman at 39 weeks' gestation arrives in the triage area of the birthing unit, stating she thinks her "water broke". What should the nurse do first?

Check the vaginal introitus for the presence of the umbilical cord

After a client gives birth, what physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of sudden gush of blood

During a client's labor, the fetal monitors a fetal heart rate pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention?

Assist the client to turn to the side-lying position

In the second stage of labor, the nurse should plan to discourage a client from holding her breath longer than 7 seconds while pushing with each contraction. What complication does this prevent?

Fetal hypoxia

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond?

Have her pant-blow during contractions

The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced, and the FHR is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?

Introduce the staff nurses to the couple and try to make them feel welcome

At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side?" What response explains the primary purpose of the side-lying position during labor?

It enhances blood flow to the uterus and contractions

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveal the cervix at 3 cm dilation and 75% effacement, +1 station with occiput anterior, and intact membranes. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. Based on observations of the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?

It's all right for you walk as long as you feel comfortable and your membranes are intact.

A nurse performs Leopold maneuvers on a pregnant client and document the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in public area; and cephalic prominence on the right side. Applying these findings, which fetal position does the nurse identify?

Left occipitoanterior (LOA)

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What should the nurse tell the client to do?

Pant while resisting the urge to bear down

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?

Push with her glottis open

Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse identifies that the fetus is experiencing late decelerations. List the following nurse action in order of priority.

Reposition on her side ----> Increase IV fluids ----> Reassess fetal heart pattern ----> If late decelerations persists, notify the health care provider ----> Document interventions with related maternal/fetal responses

A nurse observes a laboring client's amniotic fluid and decided it is the expected color. What description of amniotic fluid supports this conclusion?

Straw colored, clear, and contains little white specks

A primipara gave birth to an infant weighting 9 pounds 15 ounces (4508 g). She had a midline episiotomy and a three-degree laceration. She tells the nurse that her perinatal area is very painful. What should the nurse consider before explaining the reason for the pain?

The anal sphincter muscle has been injured

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and asks the nurse, "Do you think it is best for me to leave, because I don't seem to be doing my wife much good?" What is the nurse's best response?

This is hard for you. Let me try to help you coach her during this difficult phase.

When a client's legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent what?

Trauma to the uterine ligaments

Why should a nurse withhold foods and oral fluids as a laboring client approaches the second stage of labor?

Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia