OB Chapter 14-Nursing Management During Labor and Birth

Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor? A) "Lying flat with your head elevated on two pillows makes pushing easier." B) "Choose whatever method you feel most comfortable with for pushing." C) " Let me help you decide when it is time to start pushing." D) "Bear down like you're having a bowel movement with every contraction."

Ans. B "Choose whatever method you feel most comfortable with for pushing." * The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push.

___________________ describes the irregular variations or absence of fetal heart rate (FHR) due to erroneous causes on the fetal monitor record.

artifact

Leopold's maneuvers steps

- Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? - Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) - Maneuver 3: What is the presenting part? - Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

- Signs that the placenta is separating include:

- a firmly contracting uterus - a change in uterine shape from discoid to globular ovoid - a sudden gush of dark blood from the vaginal opening - and lengthening of the umbilical cord protruding from the vagina.

The extent of the laceration is defined by depth:

- a first-degree laceration extends through the skin - a second-degree laceration extends through the muscles of the perineal body - a third-degree laceration continues through the anal sphincter muscle - a fourth-degree laceration also involves the anterior rectal wall.

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? A. Increased sedation B. Newborn respiratory depression C. Nervous system depression D. Decreased alertness

- increase sedation is an adverse effect of lorezapam - diazepam and midazolam cause CNS depression - opiods cause newborn respiration depression

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this women? (Select all that apply.) A) Administration of penicillin G at the onset of labor B) Avoidance of scalp electrodes for fetal monitoring C) Refraining from obtaining fetal scalp blood for pH testing D) Administering zidovudine at the onset of labor. E) Electing for the use of forceps-assisted delivery

-Avoidance of scalp electrodes for fetal monitoring -Refraining from obtaining fetal scalp blood for pH testing -Administering zidovudine at the onset of labor

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following? A) Respiratory depression B) Urinary retention C) Abdominal distention D) Hyperreflexia

A.

A woman has just entered the second stage of labor. The nurse would focus care on which of the following? A) Encouraging the woman to push when she has a strong desire to do so B) Alleviating perineal discomfort with the application of ice packs C) Palpating the woman's fundus for position and firmness D) Completing the identification process of the newborn with the mother

A. During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A) +2 station B) 0 station C) -2 station D) Crowning

C. The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station.

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

Lower quadrant of the maternal abdomen

After teaching a group of students about fetal heart rate patterns, the instructor determines the need for additional teaching when the students identify which of the following as indicating normal fetal acid-base status? (Select all that apply.) A) Sinusoidal pattern B) Recurrent variable decelerations C) Fetal bradycardia D) Absence of late decelerations E) Moderate baseline variability

Sinusoidal pattern Recurrent variable decelerations Fetal bradycardia

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?

every 30 minutes

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding? A. Monitor vital signs B. Assess amount of cervical dilation C. Obtain urine speicmen for urinalysis D. Monitor hydration status

if vaginal bleeding is absent during admission assessment, nurse should perform vaginal examination to assess amount of cervical dilation

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful? A) "We can get up and walk around after receiving combined spinal-epidural analgesia." B) "Higher anesthetic doses are needed for patient-controlled epidural analgesia. C) "A pudendal nerve block is highly effective for pain relief in the first stage of labor." D) "Local infiltration using lidocaine is an appropriate method for controlling contraction pain."

A. When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, combined spinal-epidural analgesia allows the woman to ambulate ("walking epidural").

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next? A) Check the fetal heart rate. B) Perform a vaginal exam. C) Notify the physician immediately. D) Change the linen saver pad.

A. When membranes rupture, the PRIORITY focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse.

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate with the Dopplar at least how often?

30 to 60 min

The woman's temperature is typically assessed every ____ hours during the first stage of labor and every ____ hours after ruptured membranes.

4 2

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do NEXT? A. Prepare the client for birth B. Assess the client's cervical status C. notify the health care provider D. perform leopold's maneuver

5 to 6 pH means acidic environment with presence of vaginal fluid and less blood. notify provider

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which of the following? A) Skin B) Muscles of perineal body C) Anal sphincter D) Anterior rectal wall

B. Muscle of perineal body

A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation? A) "This technique focuses on manipulating body tissues." B) "The technique requires focusing on a specific stimulus." C) "This technique redirects energy fields that lead to pain." D) "The technique involves light stroking of the abdomen with breathing."

C. "This technique redirects energy fields that lead to pain." -Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain. - Attention focusing and imagery involve focusing on a specific stimulus. - Massage focuses on manipulating body tissues. - Effleurage involves light stroking of the abdomen in rhythm with breathing.

A client states, "I think my waters broke! I felt this gush of fluid between my legs." The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns: A) Yellow B) Olive green C) Pink D) Blue

D. Amniotic fluid is alkaline and turns Nitrazine paper blue. * Nitrazine paper that remains yellow to olive green suggests that the membranes are most likely intact.

A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate understanding of the information when they identify which agent as the most commonly used opioid? A) Butorphanol B) Nalbuphine C) Fentanyl D) Meperidine

D. Meperidine

A nurse is completing the assessment of a woman admitted to the labor and birth suite.Which of the following would the nurse expect to include as part of the physical assessment? (Select all that apply.) A) Current pregnancy history B) Fundal height measurement C) Support system D) Estimated date of birth E) Membrane status F) Contraction pattern

Fundal height measurement Membrane status Contraction pattern As part of the admission physical assessment, the nurse would assess: - fundal height - membrane status and contractions * Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? A. Local infiltration B. Epidural block C. Regional anesthesia D. General anesthesia

General anesthesia is administered in emergency cesarean births

A nurse caring for a pregnant client in labor observes that the fetal heart rate is below 110 per minute. Which interventions should the nurse perform?

O2 mask

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as?

Possible infection

If the nitrazine test is inconclusive, an additional test, called the ________________ test, can be used to confirm rupture of membranes

fern

Of all of the synthetic opioids ___________ is the most commonly used opioid for the management of pain during labor.

meperidine

- Green fluid may indicate that the fetus has passed meconium secondary to:

hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy. - Cloudy or foul-smelling amniotic fluid indicates __________ .

infection

FHR is assessed every 30 to 60 minutes during the _________ phase of labor.

latent

Respiratory depression Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of ____________

naloxone.

Fetal _______________ as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention.

tachycardia

Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? (Select all that apply.) A) Walking with partner support B) Straddling with forward leaning over a chair C) Closed knee-chest position D) Rocking back and forth with foot on chair E) Supine with legs raised at a 90-degree angle

-Walking with partner support -Straddling with forward leaning over a chair -Rocking back and forth with foot on chair

Positioning during the first stage of labor includes:

-walking with support from the partner - side-lying with pillows between the knees - leaning forward by straddling a chair, table, or bed or kneeling over a birthing ball -lunging by rocking weight back and forth with a foot up on a chair or birthing ball or an open knee-chest position.

For continuous internal electronic fetal monitoring, four criteria must be met:

1. ruptured membranes 2. cervical dilation of at least 2 cm 3. fetal presenting part low enough to allow placement of the electrode 4. skilled practitioner available to insert the electrode.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next? A) Continue to monitor the FHR because this pattern is benign. B) Perform a vaginal exam to assess cervical dilation and effacement. C) Stay with the client while reporting the finding to the physician. D) Administer oxygen after turning the client on her left side.

A Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions.

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.

A. - The first maneuver involves feeling for the buttocks and head. - Next the nurse palpates on which side the fetal back is located. - The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. - The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

Which of the following is a priority when caring for a woman during the fourth stage of labor? A) Assessing the uterine fundus B) Offering fluids as indicated C) Encouraging the woman to void D) Assisting with perineal care

A. During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage.

A nurse palpates a woman's fundus to determine contraction intensity. Which of the following would be most appropriate for the nurse to use for palpation? A) Finger pads B) Palm of the hand C) Finger tips D) Back of the hand

A. To palpate the fundus for contraction intensity, the nurse would place the pads of the fingers on the fundus and describe how it feels.

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching? A) "This type of monitoring is the most accurate method for our baby." B) "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C) "This type of monitoring can only be used after my membranes rupture." D) "You'll be inserting a special electrode into my baby's scalp."

B. With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. *Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required? A) Intact membranes B) Cervical dilation of 2 cm or more C) Floating presenting fetal part D) A neonatologist to insert the electrode

B. For continuous internal electronic fetal monitoring, four criteria must be met: 1. ruptured membranes 2. cervical dilation of at least 2 cm 3. fetal presenting part low enough to allow placement of the electrode 4. skilled practitioner available to insert the electrode.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following? A) Early decelerations B) Variable decelerations C) Prolonged decelerations D) Late decelerations

B. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns.

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? A) Every 2 to 4 hours B) Every 45 to 60 minutes C) Every 15 to 30 minutes D) Every 10 to 15 minutes

C. During the active phase of labor, FHR is monitored every 15 to 30 minutes.

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A) Butorphanol B) Fentanyl C) Naloxone D) Promethazine

C. Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression.

When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR? A) Over the uterine fundus where contractions are most intense B) Above the umbilicus toward the right side of the diaphragm C) Between the umbilicus and the symphysis pubis D) Between the xiphoid process and umbilicus

C. - The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. - The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A) Intense B) Strong C) Moderate D) Mild

C. -A contraction that feels like the chin typically represents a moderate contraction. -A contraction described as feeling like the tip of the nose indicates a mild contraction. - A strong contraction feels like the forehead.

A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which of the following would be done next? A) Suctioning of the mouth and nose B) Clamping of the umbilical cord C) Checking for the cord around the neck D) Drying of the newborn

C. Checking for the cord around the neck once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. * Then the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium.

When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next? A) Have the woman change her position. B) Administer oxygen. C) Notify the health care provider. D) Continue to monitor the pattern every 15 minutes.

C. Fetal tachycardia as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention. The health care provider should be notified immediately and then measures should be instituted such as having the woman lie on her side and administering oxygen.

A nurse is providing care to a woman during the third stage of labor. Which of the following would alert the nurse that the placenta is separating? A) Boggy, soft uterus B) Uterus becoming discoid shaped C) Sudden gush of dark blood from the vagina D) Shortening of the umbilical cord

C. Sudden gush of dark blood from the vagina

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A) "The warmth and buoyancy of the water has a nice relaxing effect." B) "I can stay in the bath for as long as I feel comfortable." C) "My cervix should be dilated more than 5 cm before I try using this method." D) "The temperature of the water should be at least 105°F."

D. The water temperature should not exceed body temperature. Therefore, a temperature of 105° F would be too warm.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? A. External electronic fetal monitoring B. Fetal blood pH C. Fetal oxygen saturation D. Fetal position

External electronic fetal monitoring is the first option that we use