Nursing care during labor and delivery (test 2)

During which stage of labor is there the highest risk?

2 (pushing)

Nursing care during Stage 4 (immediate post partum)

BP, TPR q15min x4 then q30 x2 then qh until stable check with each vs: fundus lochia perineum bladder level of comfort anesthesia level mobility client/family response to infant; encourage bonding, maintain skin to skin hygiene assist with infant as needed assess infant well-being (RR, color, HR, T, dry, feeding) infant erythromycin (eye drop abx), Vit K (vastus lateralis) provide food and fluids

When performing vaginal examinations on a laboring woman, the nurse should be guided by what principle? a. Cleanse the vulva and perineum before and after the examination as needed. b. Wear a clean glove lubricated with tap water to reduce discomfort. c. Perform the examination every hour during the active phase of the first stage of labor. d. Perform an examination immediately if active bleeding is present.

a Cleansing will reduce the possibility that secretions and microorganisms will ascend into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should be performed only as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present, because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman G1P0000? SATA a. after vaginal examinations b. before administration of analgesics c. periodically at the end of a contraction d. every ten minutes d. before ambulating

a, b, c, e

chapter 19 key points

the onset of labor may be difficult to determine for both nulliparous and multiparous women the familiar environment of her home is most often the ideal place for a woman during the latent phase of the first stage of labor the nurse assumes much of the responsibility for assessing the progress of labor and for keeping the nurse-midwife or physician informed about that progress and deviations from expected findings the fetal heart rate and pattern reveal the feta response to the stress of the labor process assessing the laboring woman's urinary output and bladder is critical to ensure her progress and to prevent bladder injury regardless of the actual labor and birth experience, the woman's or couple's perception of the birth experience is most likely to be positive when events and performances are consistent with expectations, especially in terms of maintaining control and adequacy of pain relief the woman's level of anxiety may increase when she does not understand what is being said to her about her labor because of the medical terminology used or because of a language barrier coaching, emotional support, and comfort measures assist the woman to use her energy constructively in relaxing and working with the contractions the progress of labor is enhanced when a woman changes her positions frequently during the first stage of labor doulas provide a continuous, supportive presence during labor that can have a positive effect on the process of childbirth and its outcome the cultural beliefs and practices of a woman and her significant others, including her partner, can have a profound influence on their approach to labor and birth siblings present for labor and birth need preparations and support for the event women wit ha history of sexual abuse often experience profound stress and anxiety during childbirth inability to palpate the cervix during vaginal examination indicates that complete effacement and full dilations have occurred and is the only certain, objective sign that the second stage has begun women may have and urge to bear down at various times during labor; for some it may be before the cervix if fully dilated and for others it may not occur until the active phase of the second stage of labor when encouraged to respond to the rhythmic nature of the second stage of labor, the woman normally changes body positions, bears down spontaneously, and vocalizes (open-glottis pushing) when she perceives the urge to push (Ferguson reflex) women should bear down several times during a contraction using the open-glottis pushing method. they should avoid sustained closed-glottis pushing because this will inhibit oxygen transport to the fetus nurses can use the role of advocate to prevent routine use of episiotomy and reduce the incidence of lacerations by empowering women to take and active role in their birth by educating health care providers about approaches to managing childbirth that reduce the incidence of perineal trauma objective signs indicate that the placenta has separated and is ready to be expelled; excessive traction (pulling) on the umbilical cord before the placenta has separated can result in maternal injury during the fourth stage of labor, the woman's fundal tone, local flow, and vital signs should be assessed frequently to ensure that she is physically recovering well after gibing birth most parents and families enjoy being able to hold, explore, and examine the baby immediately after the birth

causes of labor pain during stage 3

often painless, uterine muscle and cervical dilation as placenta is passes

Nursing care during Stage 1 (early labor)

orient to room and procedures, staff resta nd refreshment for support person establish nurse-patient relationship enema, perineal prep as ordered assess learning needs and begin teaching comfort measures positions changes fluids as allowed, monitor fluid status focus assessments BP, P, R qh T q4h (q2 if ROM) FHR qh UC q30min bladder status coping and pain control assess delivery room supplies and readiness

nitrazine swab

pH test used to determine if membranes have ruptured normal vaginal environment is acidic (yellow swab) amniotic fluid is much less acidic, often neutral (blue swab)

fern test

posterior vaginal swab is allowed to dry on a glass slide and then viewed with a low power microscope fern pattern is observed wide: cervical mucus thin: amniotic fluid used to indicate leaking membranes

A woman has contractions q2-5min and a duration of 45-60 seconds. Which assessments would the RN include in her care? SATA a. FHR b. frequency of contractions c. pain level of the client d. woman's coping techniques

a, b, c, and d

supplies needed for delivery

you need at least: gloves cord clamp delivery location something to clear baby's airway

A low risk 38 week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue a when I went to the bathroom I'm bleeding." Which of the following responses should the nurse make first? a. Does it burn when you void b. You sound frightened c. That is just the mucous plug d. How much blood is there?

b (acknowledge fear before making other comments or asking questions)

AmniSure

chemical test used to determine if membranes have ruptured/leaked reads like a pregnancy dipstick 1 line = control (the test worked) 2 lines = positive for amniotic fluid

Nursing care during Stage 3 (placenta)

give Oxytocics as ordered (pitocin, methergine) assess maternal and newborn well-being initiate skin to skin, feeding infant APGAR score

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Biofeedback.

a Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain but it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

With regard to breathing techniques during labor, maternity nurses should be aware that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation

a First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor, when the cervix is dilated 8 to 10 cm. Patterned-paced breathing can sometimes lead to hyperventilation.

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

a Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol and Nubain are opioid agonist-antagonist analgesics.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes that: a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.

a Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Nurses should be aware of the difference that experience can make in labor pain, such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

a Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? a. apply heat to the woman's back b. inquire regarding the woman's pain level c. make sure that the woman's head is covered d. accept the woman's loud verbalizations

b

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: a. Encouraging the woman to try various upright positions, including squatting and standing. b. Telling the woman to start pushing as soon as her cervix is fully dilated. c. Continuing an epidural anesthetic so that pain is reduced and the woman can relax. d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

a Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. An epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

A woman is receiving nitrous oxide for pain relief in the first stage of labor. Nursing assessments would include which of the following? SATA a. assessment for n/v b. education about movement while using c. education about process of administration d. assessment of v/s

a, b, c, and d

Which nursing assessments should be done upon admission to labor? SATA a. current fetal activity b. due date of baby c. status of membranes d. gravida status

a, b, c, and d

A client enters the L/D suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? SATA a. weight gain b. ethnicity and religion c. age d. type of insurance e. gravidity and parity

a, b, c, e

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? SATA a. bulging perineum b. increased bloody show c. spontaneous rupture of the membranes d. uncontrollable urge to push e. inability to breathe through contractions

a, b, d

A woman has just arrived at the L/D suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? SATA a. fetal heart rate b. contraction pattern c. urinalysis d. vital signs e. biophysical profile

a, b, d

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? SATA a. assess fetal heart rate b. infuse 1000 mL of ringer's lactate c. place the woman in the trendelenburg position d. monitor blood pressure every 5 minutes for 15 minutes e. have the woman empty her bladder

a, b, e

In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide (N2O) in a N2O 50% / O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? a. nausea b. hypotension c. dehydration d. light-headedness e. late fetal heart decelerations

a, d

physical exam data

abdominal exam (lie, presentation, fundal height, FHR, UC) EFM or FHR and UC pattern vital signs pelvic exam for dilation, effacement, station, fetal position presence of amniotic fluid, character -fern test, nitrizine, Amnisure presence of bleeding bladder status

APGAR components

appearance (color) blue all over blue extremities not blue pulse (heart rate) 0 bpm <100 bpm >100 bpm grimace no response to stimulation grimace/feeble cry when stimulated sneezing/coughing/pulling away when stimulated activity (tone) no movement some movement active movement respirations no breathing weak/slow/irregular strong cry

A client in labor, G2P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? a. the client had poor childbirth education prior to labor b. the client is exhibiting an expected behavior for labor c. the client is becoming hypoxic and hypercapnic d. the client needs her alpha-fetoprotein levels checkes

b

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? a. assess the blood pressure b. have the woman breathe into a bag c. turn the woman onto her side e. check the fetal heart rate

b

A woman is in the second stage of labor with a strong urge to push. which of the following actions by the nurse is appropriate at this time? a. assess the fetal heart rate between contractions every 60 minutes b. encourage the woman to grunt during contractions c. assess the pulse and respirations of the mother every 5 minutes d. position the woman on her back with her knees on her chest

b

Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-refieveing methods? a. epidural b. nitrous oxide c. narcotic analgesic d. spinal

b

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? a. paresthesias in her feet and legs b. drop in blood pressure c. increase in central venous pressure d. fetal heart accelerations

b

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? a. lying in the lithotomy position b. performing effleurage c. practicing Kegel exercises d. pushing with each contraction

b

Under which circumstance would a nurse not perform a vaginal examination on a patient in labor? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture Incorrect

b An accelerated FHR is a positive sign not requiring vaginal examination; variable decelerations, however, merit a vaginal examination. Vaginal examination should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is another appropriate time to perform a vaginal examination, as is after rupture of membranes (ROM). The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM.

After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Visceral b. Referred c. Somatic d. Afterpain

b As labor progresses the woman often experiences referred pain. It occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and the thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. It results from stretching of the perineal tissues and the pelvic floor and occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. IM administration is preferred over IV administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

b Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

Which test is performed to determine whether membranes are ruptured? a. Urine analysis b. Fern test c. Leopold maneuvers d. AROM

b In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery to determine the presence or absence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of postbirth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together

b The headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You may have an epidural. You won't feel anything."

b This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. The statement in A negates the woman's fears and is not therapeutic. The statement in C also negates the woman's fears and offers a false sense of security. The statement in D is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? a. awaken the woman and remind her to push b. cover the woman's perineum with a sheet c. assess the woman's blood pressure and pulse d. administer oxygen to the woman via face mask

b (it would be appropriate to awaken the mother at the start of the the next contraction)

A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? a. assess the woman's temperature b. place a wedge under the woman's side c. place a blanket roll under the woman's feet d. assess the woman's pedal pulses

b (tilt the uterus to relieve pressure on the great veins and avoid hypotension)

A laboring woman has a distended bladder. Her nurse advises her to void regularly for what reason? SATA a. a full bladder strengthens contractions b. an empty bladder facilitates descent c. an empty bladder provides for comfort d. a full bladder increases risk of hemorrhage

b and c

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? a. epidurals do not work well when the pain level is above level 5 b. i will contact the doctor to get an order for an epidural right away c. the baby is going to be born very soon it is really too late for an epidural d. i will check the fetal heart rate. you can have an epidural if it is over 120

c

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? a. Report the findings to the woman's healthcare practitioner b. immediately assess the woman's pulse and blood pressure c. continue to provide encouragement during each contraction d. place the client on her side with oxygen via face mask

c

A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? a. variable decelerations b. late decelerations c. decreased variability d. transient accelerations

c

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? a. mothers who are performing breathing exercises during labor refrain from yelling b. breathing and relaxation exercises are less exhausting that crying and moaning c. knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle childbirth education classes help to promote positive maternal-newborn bonding

c

Which description of the phases of the second stage of labor is accurate? a. Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes b. Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes c. Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies d. Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes

c The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down" period, at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? a. The healthy newborn should be taken to the nursery for a complete assessment. b. After drying, the infant should be given to the mother wrapped in a receiving blanket. c. Skin-to-skin contact of mother and baby should be encouraged. d. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

c The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. Although complete assessment in the nursery is the practice in many facilities, it is neither evidence-based nor supportive of family-centered care. Handing the mother the blanket-wrapped baby is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed on the mother skin to skin. The father or support person is likely also anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin with the mother and breastfeeding has been initiated.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: a. Either hot or cold applications may provide relief, but they should never be used together in the same treatment. b. Acupuncture can be performed by a skilled nurse with just a little training. c. Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. Correct d. Therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

c The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates her understanding of the instructions when the woman states: a. "True labor contractions will subside when I walk around." b. "True labor contractions will cause discomfort over the top of my uterus." c. "True labor contractions will continue and get stronger even if I relax and take a shower." d. "True labor contractions will remain irregular but become stronger."

c True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions stop with walking or a change of position.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? SATA a. hypnotic suggestions b. rhythmic chanting c. muscle relaxation d. pelvic rocking e. abdominal massage

c, d, e

Nursing care during Stage 2 (pushing)

coach/support maternal positioning comfort measures physician/CNM contact bladder status UC, FHR q5min

Nursing care during Stage 1 (active)

comfort measures position changes breathing IV as needed, monitor fluid status analgesia and anesthetic prn focused assessment BP, P, R qh T q4 (q2 if ROM) FHR, UC q30min bladder status vaginal bleeding/discharge assess delivery room supplies and readiness during Transition: BP, TPR q30min FHR, UC q15min

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? a. hold her breath for twenty seconds during every contraction b. blow out forcefully during every contraction c. push between contractions until the fetal head is visible d. take a slow cleansing breath before bearing down

d

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? a. leopold maneuvers b. fundal contractility c. fetal heart assessment d. vaginal examination

d

It is 4 pm. A client, G1P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: a. laboring clients are never allowed to eat b. believe me, you will not want to eat by the time it i the dinner hour. most women throw up, you know c. the dinner tray should arrive in an hour or two d. a heavy meal is discouraged. i can get clear fluids for you whenever you would like them, though

d

The nurse documents in a laboring woman's chart that the fetal heart is being assessed via intermittent auscultation. To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following time? a. after every contraction b. for 10 minutes every half hour c. only during the peak of contractions d. for 1 minute immediately after contractions

d

In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Encouraging expectant parents to attend childbirth preparation in any or no specific method

d Encouraging expectant parents to attend class is most important, because preparation increases a woman's confidence and thus her ability to cope with labor and birth. The goal is to encourage new parents to attend any one of the acceptable childbirth education programs. Gaining in popularity are Birthing from Within and Hypnobirthing. The Dick-Read method is historically popular and is still in use. The Lamaze method is less focused on a method approach and more concerned with psychologic preparation for labor. Attendance at any available class should be encouraged, however. Bradley as well as other methods encourage women to choose the techniques that work best for them. Women are helped to develop their own birth philosophy and then choose from a variety of skills to help cope with the labor process.

In a variation of rooming-in called couplet care, the mother and infant share a room and the mother shares the care of the infant with: a. The father of the infant. b. Her mother (the infant's grandmother). c. Her eldest daughter (the infant's sister). d. The nurse.

d In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room maternity care. The father is included in instruction regarding infant care whenever he is present. The grandmother is welcome to stay and take part in the woman's postpartum care, but she is not part of the couplet. An older sibling may stay with the client and her baby but is also not part of the couplet.

Which of the following would not be included in a labor nurse's plan of care for an expectant mother? a. The onset of progressive, regular contractions b. The bloody, or pink, show c. The spontaneous rupture of membranes d. Formulation of the woman's plan of care for labor

d Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment.

If a woman complains of back labor pain, the nurse might best suggest that she: a. Lie on her back for a while with her knees bent. b. Do less walking around. c. Take some deep, cleansing breaths. d. Lean over a birth ball with her knees on the floor.

d The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. Deep cleansing breaths will assist with any labor pain; however, it is very important that this woman's position is changed so that she is not on her back.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a. Notify the woman's physician. b. Tell the woman to slow the pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag.

d This client is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, and circumoral numbness. Notification of the physician is not necessary. The best approach is to have the client breathe into a paper bag held tightly around the nose and mouth to eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Slowing the pace of her breathing will not correct the problem, nor will administration of oxygen. Once the pattern of breathing is corrected, her partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues.

nonpharmacologic pain relief measures

explanation/encouragement gate control theory focusing imagery breathing techniques effleurage sacral counter pressure, double hip squeeze touch/massage water theraphy relaxation techniques position changes (esp with back labor) TENS unit distraction hot/cold compresses temperature control (take care that it's not too cold for baby, point fan at mom)

pharmacologic methods of pain control

higher risk requires fetal monitoring analgesia: demerol stadol nubain *NARCAN (antagonist for OD) anesthesia -regional: logan pudendal (saddle block, used in assisted delivery) paracervical epidural spinal -nitrous oxide -general

side effects of epidural and spinal anesthesia

hypotension fever urinary rethetion pruritus limited movement longer second stage labor increased use of oxytocin increased likelihood of forceps or vacuum assisted birth high or total spinal anesthesia local anesthetic toxicity: lightheadedness dizziness tinnitus metallic taste numbness in the tongue and mouth bizarre behavior slurred speech convulsions loss of consciousness

maternal signs of transition

involuntary pushing (when mom feels pressure on bowel) moisture on upper lip urge to bear down cleansing breaths at the beginning and end of contractions

fetal heart rate monitoring during labor

let mom get up and move -labor progression -pain control constant monitoring is indicated with pitocin and epidural

chapter 17 key points

nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods the gate-control theory of pain and the stress response are the bases for many of the nonpharmacologic methods of pain relief the type of analgesic or anesthetic to be used is determined by maternal and health care provider preference, the stage of labor, and the method of birth sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest naloxone (Narcan) is an opioid antagonist that can reverse narcotic effects, especially respiratory depression pharmacologic control of pain during labor requires collaboration among the health care providers and the laboring woman the nurse must understand medications, their expected effects, potential side effects, and methods of administration maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response the use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal) epidural anesthesia and analgesia is the most effective available pharmacologic pain relief method for labor. it is used by the majority of women in the US general anesthesia is rarely used for vaginal birth but may be used for cesarean birth or whenever rapid anesthesia is needed in an emergency childbirth situation

factors which affect pain perception

previous experience level of anxiety self concept (preparations, nurturing, overall) amount of distraction and attention other illnesses history of substance abuse culture (concept and experience with pain, cultural mode of expression when in pain, cultural expectation of the nurse role)

nursing assessment

upon admission to L/D: -review prenatal records; note any risk factors and areas of concern/need -obtain admission data (age, GTPAL, EDC, ROM) true vs false labor fetal activity current meds/allergies prenatal problems bloody show vs bleeding onset of labor/pattern of UC CB prep/birth plan feeding method pediatrician choice last food/fluid ingested last void/BM recent sleep patterns client/family concerns or questions physical exam

causes of labor pain during stage 1

visceral dilation of the cervix hypoxia of the uterine muscle cells during contractions stretching of the lower uterine segment referred pain from lower abdominal wall, lumbar, and sacral regions

causes of labor pain during stage 2

visceral and somatic hypoxia of the uterine muscle cells distention of the vagina and perineum pressure on adjacent structures