OB Exam Two

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand? a. Client is considered in active labor when she arrives at the facility with contractions. b. Client can have only her male partner or predesignated doula with her at assessment. c. Children are not allowed on the labor unit. d. Non-English speaking client must bring someone to translate.

ANS: A, According to the Emergency Medical Treatment and Active Labor Act (EMTALA), a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman may have anyone she wishes present for her support. An interpreter must be provided by the hospital, either in person or by a telephonic service. Siblings of the new infant may be allowed at the delivery, depending on hospital policy and adequate preparation and supervision.

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory? a. Massaging the woman's back. b. Changing the woman's position. c. Giving the prescribed medication. d. Encouraging the woman to rest between contractions

ANS: A, According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques, such as massage or stroking, music, focal points, and imagery, reduce or completely block the capacity of the nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, administering pain medication, and resting between contractions do not reduce or block the capacity of the nerve pathways to transmit pain using the gate-control theory.

In assessing the immediate condition of the newborn after birth, a sample of cord blood may be a useful adjunct to the Apgar score. Cord blood is then tested for pH, carbon dioxide, oxygen, and base deficit or excess. Which clinical situation warrants this additional testing? (Select all that apply.) a. Low 5-minute Apgar score b. Intrauterine growth restriction (IUGR) c. Maternal thyroid disease d. Intrapartum fever e. Vacuum extraction

ANS: A, B, C, D, The American College of Obstetricians and Gynecologists (ACOG) suggests obtaining cord blood values in all of these clinical situations except for vacuum extractions deliveries. Cord blood gases should also be performed for multifetal pregnancies or abnormal FHR tracings. Samples can be drawn from both the umbilical artery and the umbilical vein. Results may indicate that fetal compromise has occurred.

Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. Which items might this plan include? (Select all that apply.) a. Presence of companions b. Clothing to be worn c. Care and handling of the newborn d. Medical interventions e. Date of delivery

ANS: A, B, C, D, The presence of companions, clothing to be worn, care and handling of the newborn, medical interventions, and environmental modifications all might be included in the couple's birth plan. Other items include the presence of nonessential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements. The expected date of delivery would not be part of a birth plan unless the client is scheduled for an elective cesarean birth.

While developing an intrapartum care plan for the client in early labor, which psychosocial factors would the nurse recognize upon the client's pain experience? (Select all that apply.) a. Culture b. Anxiety and fear c. Previous experiences with pain d. Intervention of caregivers e. Support systems

ANS: A, B, C, E

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a. Nonreassuring or abnormal fetal heart rate (FHR) pattern b. Inadequate uterine relaxation c. Vaginal bleeding d. Prolonged second stage e. Prolapse of the cord

ANS: A, B, C, E, A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention. A prolonged second stage of labor after the upper limits for duration is reached. This is 3 hours for nulliparous women and 2 hours for multiparous women.

Which alternative approaches to relaxation have proven successful when working with the client in labor? (Select all that apply.) a. Aromatherapy b. Massage c. Hypnosis d. Cesarean birth e. Biofeedback

ANS: A, B, C, E, Approaches to relaxation can include neuromuscular relaxation, aromatherapy, music, massage, imagery, hypnosis, or touch relaxation. Cesarean birth is a method of delivery, not a method of relaxation

A woman has requested an epidural block for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. Before the initiation of the epidural, the woman should be informed regarding the disadvantages of an epidural block. Which concerns should the nurse share with this client? (Select all that apply.) a. Ability to move freely is limited. b. Orthostatic hypotension and dizziness may occur. c. Gastric emptying is not delayed. d. Higher body temperature may occur. e. Blood loss is not excess

ANS: A, B, D, The woman's ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (IV lines and electronic fetal monitoring [EFM]). Significant disadvantages of an epidural block include the occurrence of orthostatic hypotension, dizziness, sedation, and leg weakness. Women who receive an epidural block have a higher body temperature (38° C or higher), especially when labor lasts longer than 12 hours, and may result in an unnecessary neonatal workup for sepsis. An advantage of an epidural block is that blood loss is not excessive. Other advantages include the following: the woman remains alert and able to participate, good relaxation is achieved, airway reflexes remain intact, and only partial motor paralysis develops.

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. Which instruction best describes these measures? 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 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

ANS: A, Both upright and squatting positions may enhance the progress of fetal descent. Many factors dictate when a woman should begin pushing. Complete cervical dilation is necessary, but complete dilation is only one factor. If the fetal head is still in a higher pelvic station, then the physician or midwife may allow the woman to "labor down" if the woman is able (allowing more time for fetal descent and thereby reducing the amount of pushing needed). The 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 her breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia.

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Which signs would indicate opioid withdrawal in the mother? (Select all that apply.) a. Yawning, runny nose b. Increase in appetite c. Chills or hot flashes d. Constipation e. Irritability, restlessness

ANS: A, C, E, The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. Assessing both the mother and the newborn and planning the care accordingly are important steps for the nurse to take. Neither an increase in appetite nor constipation are associated with opioid withdrawal.

The nurse should be aware of which important information regarding nerve block analgesia and anesthesia? a. Most local agents are chemically related to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. Pudendal nerve block is designed to relieve the pain from uterine contractions. d. Pudendal nerve block, if performed correctly, does not significantly lessen the bearing-down reflex.

ANS: A, Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contraction. A pudendal nerve block lessons or shuts down the bearing-down reflex.

A client is experiencing back labor and reports intense pain in her lower back. Which measure provided by the woman's labor coach would best support this woman in labor? a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques c. Effleurage d. Conscious relaxation or guided imagery

ANS: 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. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: A, Early decelerations are the fetus' response to fetal head compression; these are considered benign, and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur? a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration

ANS: A, Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the administration of magnesium sulfate will each more likely result in fetal bradycardia, not tachycardia.

Which client would not be a suitable candidate for internal electronic fetal monitoring (EFM)? a. Client who still has intact membranes b. Woman whose fetus is well engaged in the pelvis c. Pregnant woman who has a comorbidity of obesity d. Client whose cervix is dilated to 4 to 5 cm

ANS: A, For internal EFM, the membranes must have ruptured and the cervix must be dilated at least 2 to 3 cm. The presenting part must be low enough to allow placement of the spiral electrode necessary for internal EFM. The accuracy of EFM is not affected by maternal size. However, evaluating fetal well-being using external EFM may be more difficult on an obese client. The client whose cervix is dilated to 4 to 5 cm is indeed a candidate for internal monitoring.

In recovery, if a woman is asked to either raise her legs (knees extended) off the bed or flex her knees, and then place her feet flat on the bed and raise her buttocks well off the bed, the purpose of this exercise is to assess what? a. Recovery from epidural or spinal anesthesia b. Hidden bleeding underneath her c. Flexibility d. Whether the woman is a candidate to go home after 6 hours

ANS: A, If the numb or prickly sensations are gone from her legs after these movements, then she has likely recovered from the epidural or spinal anesthesia. Assessing the client for bleeding beneath her buttocks before discharge from the recovery is always important; however, she should be rolled to her side for this assessment. The nurse is not required to assess the woman for flexibility. This assessment is performed to evaluate whether the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse's first priority? a. Change the woman's position. b. Notify the health care provider. c. Assist with amnioinfusion d. Insert a scalp electrode.

ANS: A, Late FHR decelerations may be caused by maternal supine hypotension syndrome. These decelerations are usually corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, then the nurse should continue with subsequent intrauterine resuscitation measures and notify the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely will reveal variable decelerations. Although a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it is not a nursing intervention that will alleviate late decelerations nor is it the nurse's first priority.

Which component of the physical examination are Leopold's maneuvers unable to determine? a. Gender of the fetus b. Presenting fetal part c. Fetal lie d. Estimated fetal size

ANS: A, Leopold's maneuvers help identify the size of the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus cannot be determined by performing Leopold's maneuvers.

Which nursing intervention would result in an increase in maternal cardiac output? a. Change in position b. Oxytocin administration c. Regional anesthesia d. IV analgesic

ANS: A, Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This position reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

What are the legal responsibilities of the perinatal nurses? a. Correctly interpreting fetal heartrate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes b. Greeting the client on arrival, assessing her status, and starting an IV line c. Applying the external fetal monitor and notifying the health care provider d. Ensuring that the woman is comfortable

ANS: A, Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients and falls within the registered nurse's scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

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 in shape. A gush of dark red blood comes from her vagina. What is the nurse's assessment of the situation? 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.

ANS: 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, then the nurse would expect to find the uterus boggy and displaced to the side.

The nurse should be aware of which physiologic effect of labor pain? a. Predominant pain of the first stage of labor is visceral pain that is in the lower portion of the abdomen. b. Referred pain is the extreme discomfort experienced between contractions. c. Somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.

ANS: A, Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is like that of the first stage.

Which alterations in the perception of pain by a laboring client should the nurse understand? a. Sensory pain for nulliparous women is often greater than for multiparous women during early labor. b. Affective pain for nulliparous women is usually 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.

ANS: 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 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 breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes? a. Slow-paced breathing b. Deep abdominal breathing c. Modified-paced breathing d. Patterned-paced breathing

ANS: A, Slow-paced breathing is approximately one half the woman's normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions. No such pattern called deep abdominal breathing exists in childbirth preparation. Modified-paced breathing is shallow breathing that is twice the woman's normal breathing rate. It is used when labor progresses, and the woman can no longer maintain relaxation through paced breathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.

Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation? a. Ritgen maneuver b. Fundal pressure c. Lithotomy position d. De Lee apparatus

ANS: A, The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is used to suction fluid from the infant's mouth.

What is the most critical nursing action in caring for the newborn immediately after the birth? a. Keeping the airway clear b. Fostering parent-newborn attachment c. Drying the newborn and wrapping the infant in a blanket d. Administering eye drops and vitamin K

ANS: A, The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, to support respiratory effort, and to prevent cold stress by drying the newborn and covering him or her with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn's physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the newborn to the partner or to the mother of the infant.

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position? a. Occiput of the fetus is in a posterior position. b. Fetus is at or above the ischial spines. c. Fetus is in a vertex presentation. d. Membranes have ruptured.

ANS: A, The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position not a vertex position. Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases, this urge is felt before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred. No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions. The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.

What is the correct placement of the tocotransducer for effective electronic fetal monitoring (EFM)? a. Over the uterine fundus b. On the fetal scalp c. Inside the uterus d. Over the mother's lower abdomen

ANS: A, The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.

When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective? a. Dilation of the cervix b. Descent of the fetus to -2 station c. Rupture of the amniotic membranes (ROM) d. Increase in bloody show

ANS: A, The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor.

Part of the nurse's role is assisting with pushing and positioning. Which guidance should the nurse provide to her client in active labor? a. Encourage the woman's cooperation in avoiding the supine position. b. Advise the woman to avoid the semi-Fowler position. c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response. d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push

ANS: A, The woman should maintain a side-lying position. The supine position can cause maternal hypotension, which impairs placental perfusion and fetal oxygenation. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, allowing air to escape during the push.

The client has delivered by urgent caesarean birth for fetal compromise. Umbilical cord gases were obtained for acid-base determination. The pH is 6.9, partial pressure of carbon dioxide (PCO2) is elevated, and the base deficit is 11 mmol/L. What type of acidemia is displayed by the infant? a. Respiratory b. Metabolic c. Mixed d. Turbulent

ANS: A, These findings are evidence of respiratory acidemia. Metabolic acidemia is expressed by a pH <7.20, normal carbon dioxide pressure, and a base excess of 12 mmol/L. Mixed acidemia is evidenced by a pH <7.20, elevated carbon dioxide pressure, and a base excess of 12 mmol/L. There is no such finding as turbulent acidemia.

A nurse caring for a woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign? a. Periodic fetal sleep state b. Extreme prematurity c. Fetal hypoxemia d. Preexisting neurologic injury

ANS: A, When the fetus is temporarily in a sleep state, minimal variability is present. Periodic fetal sleep states usually last no longer than 30 minutes. A woman in labor with extreme prematurity may display a FHR pattern of minimal or absent variability. Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. Congenital anomalies or a preexisting neurologic injury may also result in absent or minimal variability. Other possible causes might be central nervous system (CNS) depressant medications, narcotics, or general anesthesia.

The nurse should be aware of which information related to a woman's intake and output during labor? a. Traditionally, restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids are usually necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will quickly follow.

ANS: A, Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. The routine use of an enema is, at best, ineffective and may be harmful. Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a nulliparous woman.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's ideal response? 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 can have an epidural. You won't feel anything."

ANS: B, "It's normal to be anxious about labor. Let's discuss what makes you afraid" is a statement that allows the woman to share her concerns with the nurse and is a therapeutic communication tool. "Don't worry about it. You'll do fine" negates the woman's fears and is not therapeutic. "Labor is scary to think about, but the actual experience isn't" negates the woman's fears and offers a false sense of security. To suggest that every woman can have an epidural is untrue. Several criteria must be met before an epidural is considered. Furthermore, many women still experience the feeling of pressure with an epidural.

What is the correct terminology for the nerve block that provides anesthesia to the lower vagina and perineum? a. Epidural b. Pudendal c. Local d. Spinal block

ANS: B, A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and the use of low forceps, if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

Which statement concerning the third stage of labor is correct? a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

ANS: B, Active management facilitates placental separation and expulsion, reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhaging.

A woman who is gravida 3 para 2 arrives on the intrapartum unit. What is the most important nursing assessment initially? a. Contraction pattern, amount of discomfort, and pregnancy history b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth c. Identification of ruptured membranes, woman's gravida and para, and her support person d. Last food intake, when labor began, and cultural practices the couple desires

ANS: B, All options describe relevant intrapartum nursing assessments; however, this focused assessment has a priority. If the maternal and fetal conditions are normal and birth is not imminent, then other assessments can be performed in an unhurried manner; these include: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices.

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. 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

ANS: B, An accelerated FHR is a positive sign; therefore, a vaginal examination would not be necessary.

Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct? a. Even mild anxiety must be treated. b. Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B, Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can sufficiently build to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could the nurse use to increase the client's blood pressure? (Select all that apply.) a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase IV fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D, Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until the woman is stable. Placing the client in a supine position causes venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

Which fetal heart rate (FHR) decelerations would require the nurse to change the maternal position? (Select all that apply.) a. Early decelerations b. Late decelerations c. Variable decelerations d. Moderate decelerations e. Prolonged decelerations

ANS: B, C, E, Early decelerations (and accelerations) do not generally need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral). Variable decelerations also require a maternal position change (side to side). Moderate decelerations are not an accepted category. Prolonged decelerations are late or variable decelerations that last for a prolonged period (longer than 2 minutes) and require intervention.

A tiered system of categorizing fetal heart rate (FHR) has been recommended by professional organizations. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. What is the correct nomenclature for these categories? (Select all that apply.) a. Reassuring b. Category I c. Category II d. Nonreassuring e. Category III

ANS: B, C, E, The three-tiered system of FHR tracings include category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate and includes tracings that do not meet category I or III criteria. Category III tracings are abnormal and require immediate intervention.

According to the National Institute of Child Health and Human Development (NICHD) Three-Tier System of FHR Classification, category III tracings include all FHR tracings not categorized as category I or II. Which characteristics of the fetal heart rate (FHR) belong in category III? (Select all that apply.) a. Baseline rate of 110 to 160 beats per minute b. Tachycardia c. Absent baseline variability not accompanied by recurrent decelerations d. Variable decelerations with other characteristics such as shoulders or overshoots e. Absent baseline variability with recurrent variable decelerations f. Bradycardia

ANS: B, D, E, F Tachycardia, variable decelerations with other characteristics, absent baseline variability with recurrent variable decelerations, and bradycardia are characteristics that are considered non-reassuring or abnormal and belong in category III. A FHR of 110 to 160 beats per minute is considered normal and belongs in category 1. Absent baseline variability not accompanied by recurrent decelerations is a category II characteristic.

A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. The nurse applies the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. What is the nurse's best response? a. "Don't worry about that machine; that's my job." b. "The baby's heart rate will fluctuate in response to what is happening during labor." c. "The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are." d. "Your physician will explain all of that later."

ANS: B, Explaining what indicates a normal fetal heart rate (FHR) teaches the partner about fetal monitoring and provides support and information to alleviate his fears. Telling the partner not to worry discredits his feelings and does not provide the teaching he is requesting. Telling the partner that the graph indicates how strong the contractions are provides inaccurate information and does not address the partner's concerns about the FHR. The EFM graphs the frequency and duration of the contractions, not their intensity. Nurses should take every opportunity to provide teaching to the client and her family, especially when information is requested.

Which characteristic correctly matches the type of deceleration with its likely cause? a. Early deceleration—umbilical cord compression b. Late deceleration—uteroplacental insufficiency c. Variable deceleration—head compression d. Prolonged deceleration—unknown cause

ANS: B, Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

According to professional standards which action cannot be performed by the non-anesthetist registered nurse who is caring for a woman with epidural anesthesia? a. Monitoring the status of the woman and fetus b. Initiating epidural anesthesia c. Replacing empty infusion bags with the same medication and concentrate d. Stopping the infusion, and initiating emergency measures

ANS: B, Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion. The non-anesthetist nurse is permitted to monitor the status of the woman, the fetus, and the progress of labor. Replacement of the empty infusion bags or syringes with the same medication and concentration is permitted. If the need arises, the nurse may stop the infusion, initiate emergency measures, and remove the catheter if properly educated to do so. Complications can require immediate interventions. Nurses must be prepared to provide safe and effective care during an emergency situation.

What is the rationale for the administration of an oxytocic after expulsion of the placenta? a. To relieve pain b. To stimulate uterine contraction c. To prevent infection d. To facilitate rest and relaxation

ANS: B, Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain, do not prevent infection, and do not facilitate rest and relaxation.

A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination? a. "The two medications, together, reduce complications." b. "Sedatives enhance the effect of the pain medication." c. "The two medications work better together, enabling you to sleep until you have the baby." d. "This is what your physician has ordered for you."

ANS: B, Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause two drugs to work together more effectively, but it does not ensure zero maternal or fetal complications. Sedation may be a related effect of some ataractic drugs; however, sedation is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. Although the physician may have ordered the medication, "This is what your physician has ordered for you" is not an acceptable comment for the nurse to make.

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity? a. To facilitate maternal-newborn interaction b. To stimulate the uterus to contract c. To prevent neonatal hypoglycemia d. To initiate the lactation cycle

ANS: B, Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhaging. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth.

Which description of the phases of the first stage of labor is most accurate? a. Latent: mild, regular contractions; no dilation; bloody show b. Active: moderate, regular contractions; 4 to 7 cm dilation c. Lull: no contractions; dilation stable d. Transition: very strong but irregular contractions; 8 to 10 cm dilation

ANS: B, The active phase is characterized by moderate and regular contractions, 4 to 7 cm dilation, and duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions, dilation up to 3 cm, brownish-to-pale pink mucus, and duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong and regular contractions, 8 to 10 cm dilation, and duration of 20 to 40 minutes.

During labor a fetus displays an average fetal heart rate (FHR) of 135 beats per minute over a 10-minute period. Which statement best describes the status of this fetus? a. Bradycardia b. Normal baseline heart rate c. Tachycardia d. Hypoxia

ANS: B, The baseline FHR is measured over 10 minutes; a normal range is 110 to 160 beats per minute. Bradycardia is a FHR less than 110 beats per minute for 10 minutes or longer. Tachycardia is a FHR higher than 160 beats per minutes for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of hypoxia exists with a baseline FHR in the normal range.

A woman who has a history of sexual abuse may have several traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. The nurse can implement appropriate care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care? a. Tell the client to relax and that it won't hurt much. b. Limit the number of procedures that invade her body. c. Reassure the client that, as the nurse, you know what is best. d. Allow unlimited care providers to be with the client.

ANS: B, The number of invasive procedures such as vaginal examinations, internal monitoring, and IV therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the client's recalling the phrases of her abuser (i.e., "Relax, this won't hurt" or "Just open your legs"). The woman's sense of control should always be maintained . The nurse should explain procedures at the client's pace and wait for permission to proceed. Protecting the client's environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe.

What is the rationale for the use of a blood patch after spinal anesthesia? a. Preventing related hypotension b. Minimizing the risk of a spinal headache c. Eliminating neonatal respiratory depression d. Limiting the loss of movement

ANS: B, The subarachnoid block may cause a post-spinal headache resulting from the loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space around the dural puncture, it forms a seal over the hole to stop the leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

Through a vaginal examination, the nurse determines that a woman is 4 cm dilated. The external fetal monitor shows uterine contractions every to 4 minutes. The nurse reports this as what stage of labor? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase

ANS: B, This maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of "laboring down."

What is the most likely cause for variable fetal heart rate (FHR) decelerations? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia

ANS: B, Variable FHR decelerations can occur at any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia continues.

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement regarding this procedure is correct? a. The application of nitrous oxide gas is not often used anymore. b. An inhalation of gas is likely to be used in the second stage of labor, not during the first stage. c. An application of nitrous oxide gas is administered for pain relief. d. The application of gas is a prelude to a cesarean birth.

ANS: C, A mixture of nitrous oxide with oxygen in a low concentration can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief. This procedure is still commonly used in Canada and in the United Kingdom. Nitrous oxide inhaled in a low concentration will reduce but not eliminate pain during the first and second stages of labor. Nitrous oxide inhalation is not generally used before a caesarean birth. Nitrous oxide does not appear to depress uterine contractions or cause adverse reactions in the newborn.

A laboring woman has received meperidine intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a. Fentanyl b. Promethazine c. Naloxone d. Nalbuphine

ANS: C, An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone, can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.

Which clinical finding indicates that the client has reached the second stage of labor? a. Amniotic membranes rupture (ROM). b. Cervix cannot be felt during a vaginal examination. c. Woman experiences a strong urge to bear down. d. Presenting part of the fetus is below the ischial spines.

ANS: C, During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. The ROM has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting fetal part is below the level of the ischial spines. This urge can occur during the first stage of labor, as early as with 5 cm dilation.

The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the client's most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (Select all that apply.) a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension

ANS: C, E, Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure, and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression, which may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when a short cord, a knot in the cord, or a prolapsed cord is present.

In which clinical situation would the nurse most likely anticipate a fetal bradycardia? a. Intraamniotic infection b. Fetal anemia c. Prolonged umbilical cord compression d. Tocolytic treatment using terbutaline

ANS: C, Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief? a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

ANS: C, Hispanic women may be stoic early in labor but more vocal and readier for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start; they may prefer pain medications. African-American women may openly express pain; the use of medications for pain is more likely to vary with the individual.

What is the primary rationale for the thorough drying of the infant immediately after birth? a. Stimulates crying and lung expansion b. Removes maternal blood from the skin surface c. Reduces heat loss from evaporation d. Increases blood supply to the hands and feet

ANS: C, Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Although rubbing the infant stimulates crying, it is not the main reason for drying the infant. This intervention would have only minimal effect of circulation to the hands and feet. This process does not remove all the maternal blood.

The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate? a. Early fetal heart rate (FHR) decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: C, Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

The nurse observes a sudden increase in variability on the electronic fetal monitoring (EFM) tracing. Which class of medications may cause this finding? a. Narcotics b. Barbiturates c. Methamphetamines d. Tranquilizers

ANS: C, Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; whereas methamphetamines may cause increased variability.

Where is the point of maximal intensity (PMI) of the fetal heart tone (FHR) located? a. Usually directly over the fetal abdomen b. In a vertex position, heard above the mother's umbilicus c. Directly over the fetal back d. In a breech position, heard below the mother's umbilicus

ANS: C, Nurses should be prepared for the shift. The PMI of the FHR is usually directly over the fetal back. In a vertex position, the PMI of the FHR is heard below the mother's umbilicus. In a breech position, it is heard above the mother's umbilicus.

Which information related to a prolonged deceleration is important for the labor nurse to understand? a. Prolonged decelerations present a continuing pattern of benign decelerations that do not require intervention. b. Prolonged decelerations constitute a baseline change when they last longer than 5 minutes. c. A disruption to the fetal oxygen supply causes prolonged decelerations. d. Prolonged decelerations require the customary fetal monitoring by the nurse.

ANS: C, Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, then the fetal cardiac tissue, itself, will become hypoxic, resulting in direct myocardial depression of the FHR. Prolonged decelerations can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting longer than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in the FHR of at least 15 beats per minute below the baseline and lasting longer than 2 minutes but shorter than 10 minutes. Nurses should immediately notify the physician or nurse-midwife and initiate appropriate treatment of abnormal patterns when they see prolonged decelerations.

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor? a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

ANS: C, Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

Which description of the phases of the second stage of labor is most accurate? a. Latent phase: Feeling sleepy; fetal station 2+ to 4+; duration of 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions; Ferguson reflux activated; duration of 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 0; duration of 15 minutes

ANS: C, The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on several factors. The latent phase is the lull or "laboring down" period at the beginning of the second stage and 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.

The first hour after birth is sometimes referred to as what? a. Bonding period b. Third stage of labor c. Fourth stage of labor d. Early postpartum period

ANS: C, The fourth stage of labor begins with the expulsion of the placenta and lasts until the woman is stable in the immediate postpartum period, usually within the first hour after birth. Maternal organs undergo their initial readjustment to a nonpregnant state. The third stage of labor lasts from the birth of the baby to the expulsion of the placenta. Bonding will occur over a much longer period, although it may be initiated during the fourth stage of labor.

A woman in labor has just received an epidural block. What is the most important nursing intervention at this time? a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C, The most important nursing intervention for a woman who has received an epidural block is for the nurse to monitor the maternal blood pressure frequently for signs of hypotension. IV fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse also observes for signs of fetal bradycardia and monitors for signs of maternal tachycardia, secondary to hypotension.

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next? a. Immediately notify the woman's primary health care provider. b. Prepare to administer an oxytocic to stimulate uterine activity. c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. d. Prepare the woman for the onset of the second stage of labor.

ANS: C, The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the client's medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips b. Determining the frequency by timing from the end of one contraction to the end of the next contraction c. Evaluating the intensity by pressing the fingertips into the uterine fundus d. Assessing uterine contractions every 30 minutes throughout the first stage of labor

ANS: C, The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. The nurse reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for this woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C, The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia and anesthesia. Typically, epidural analgesia and anesthesia are used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit levels are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.

What is a distinct advantage of external electronic fetal monitoring (EFM)? a. The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate (FHR). b. The toco transducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions. c. The toco transducer is especially valuable for measuring uterine activity during the first stage of labor. d. Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C, The toco transducer is valuable for measuring uterine activity during the first stage of labor and is especially true when the membranes are intact. Short-term variability and beat-to-beat changes cannot be measured with this technology. The toco transducer cannot measure and record the intensity of uterine contractions. The transducer must be repositioned when the woman or the fetus changes position.

A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior? a. A nulliparous woman will experience a strong urge to bear down. b. Perineal bulging will show. c. A nulliparous woman will remain quiet with her eyes closed between contractions. d. The amount of bright red bloody show will increase.

ANS: C, The woman is able to relax and close her eyes between contractions as the fetus passively descends. The woman may be very quiet during this phase. During the latent phase of the second stage of labor, the urge to bear down is often absent or only slight during the acme of the contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin. She presses her call light, and asks for her nurse right away, stating "I'm bleeding a lot." What is the most likely cause of postpartum hemorrhaging in this client? a. Retained placental fragments b. Unrepaired vaginal lacerations c. Uterine atony d. Puerperal infection

ANS: C, This woman gave birth to a macrosomic infant after oxytocin augmentation. Combined with these risk factors, uterine atony is the most likely cause of bleeding 4 hours after delivery. Although retained placental fragments may cause postpartum hemorrhaging, it is typically detected within the first hour after delivery of the placenta and is not the most likely cause of the hemorrhaging in this woman. Although unrepaired vaginal lacerations may also cause bleeding, it typically occurs in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding that is, however, typically detected 24 hours postpartum.

The nurse providing care for a high-risk laboring woman is alert for late fetal heart rate (FHR) decelerations. Which clinical finding might be the cause for these late decelerations? a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid

ANS: C, Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. Umbilical cord compression results in variable FHR decelerations. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

Which definition of an acceleration in the fetal heart rate (FHR) is accurate? a. FHR accelerations are indications of fetal well-being when they are periodic. b. FHR accelerations are greater and longer in preterm gestations. c. FHR accelerations are usually observed with breech presentations when they are episodic. d. An acceleration in the FHR presents a visually apparent and abrupt peak.

ANS: D Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in the FHR above the baseline rate. Periodic accelerations occur with uterine contractions and are usually observed with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Preterm accelerations peak at 10 beats per minute above the baseline and last for at least 10 seconds.

The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia, general anesthesia will be used. What is the greatest risk of administering general anesthesia to the client.? a. Respiratory depression b. Uterine relaxation c. Inadequate muscle relaxation d. Aspiration of stomach contents

ANS: D, Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia but can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide initially? a. Notify the woman's health care provider. b. Administer the prescribed narcotic analgesic. c. Assure her that her labor will be over soon. d. Assist her with simple breathing and relaxation instructions.

ANS: D, By reducing tension and stress, both focusing, and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful. The nurse can independently perform many functions in labor and birth, such as teaching and support. Pain medication may be an option for this client. However, the initial response of the nurse should include teaching the client about her options. The length of labor varies among individuals, but the first stage of labor is the longest. Providing false assurances will only cause the client more emotional distress. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.

An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, "My contractions are so strong, I don't know what to do." What should the nurse's first action be? a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized

ANS: D, Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. This scenario includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.

What physiologic change occurs as the result of increasing the infusion rate of nonadditive IV fluids? a. Maintaining normal maternal temperature b. Preventing normal maternal hypoglycemia c. Increasing the oxygen-carrying capacity of the maternal blood d. Expanding maternal blood volume

ANS: D, Filling the mother's vascular system increases the amount of blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions experience more pain. d. Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.

ANS: D, Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

Which fetal heart rate (FHR) finding is the most concerning to the nurse who is providing care to a laboring client? a. Accelerations with fetal movement b. Early decelerations c. Average FHR of 126 beats per minute d. Late decelerations

ANS: D, Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR finding of 126 beats per minute is normal and not a concern.

Which collection of risk factors will most likely result in damaging lacerations, including episiotomies? a. Dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. Reddish-haired mother of two who is going through a breech birth c. Dark-skinned first-time mother who is going through a long labor d. First-time mother with reddish hair whose rapid labor was overseen by an obstetrician

ANS: D, Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient. The rate of episiotomies is higher when obstetricians rather than midwives attend the births. The woman in the first scenario (a) is at low risk for either damaging lacerations or an episiotomy. She is multiparous, has dark skin, and is being attended by a midwife, who is less likely to perform an episiotomy. Reddish-haired women have tissue that is less distensible than that of darker-skinned women. Consequently, the client in the second scenario (b) is at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy. The fact that the woman in the third scenario (c) is experiencing a prolonged labor might increase her risk for lacerations. Fortunately, she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury.

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles. When is it appropriate to instruct the client to use this maneuver? a. During the second stage to enhance the movement of the fetus b. During the third stage to help expel the placenta c. During the fourth stage to expel blood clots d. During no stage of labor

ANS: D, The client should not be instructed to use this maneuver. This process stimulates the parasympathetic division of the autonomic nervous system and produces a vagal response (decrease in heart rate and blood pressure.) An alternative method includes instructing the client to perform open-mouth and open-glottis breathing and pushing.

The nurse performs a vaginal examination to assess a client's labor progress. Which action should the nurse take next? a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.

ANS: D, The nurse should discuss the findings of the vaginal examination with the woman and her partner, as well as report the findings to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned so as to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

In which situation would the nurse be called on to stimulate the fetal scalp? a. As part of fetal scalp blood sampling b. In response to tocolysis c. In preparation for fetal oxygen saturation monitoring d. To elicit an acceleration in the fetal heart rate (FHR)

ANS: D, The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse's highest priority in this situation? a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate (FHR) and pattern.

ANS: D, The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the rupture of membranes (ROM) to ascertain fetal well-being, and the findings should be documented. The ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary health care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is approximately twice the normal adult breathing rate. She starts to report feeling lightheaded and dizzy and states that her fingers are tingling. Which intervention should the nurse immediately initiate? a. Contact the woman's health care provider. b. Tell the woman to slow her pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag.

ANS: D, This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis and enable her to rebreathe carbon dioxide and replace the bicarbonate ion. It is unlikely the woman will be able to follow instructions to slow her breathing since there is a physiological cause for the hyperventilation. The woman is in need of carbon dioxide not oxygen. The health care provider is notified only if all appropriate interventions fail to help normalize the client's breathing.

A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural "no matter what!" What is the nurse's best response? a. "I'll make sure you get your epidural." b. "You may only have an epidural if your physician allows it." c. "You may only have an epidural if you are going to deliver vaginally." d. "The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth."

ANS: D, To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm. A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained. A physician's order is required for pharmacologic options for pain management. However, expressing this requirement is not the nurse's best response. An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.

The nurse is evaluating the electronic fetal monitoring (EFM) tracing of the client who is in active labor. Suddenly, the fetal heart rate (FHR) drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next? a. Call for help. b. Insert a Foley catheter. c. Start administering Pitocin. d. Immediately notify the care provider.

ANS: D, To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluids, and provide oxygen. If oxytocin is infusing, then it should be discontinued. If the FHR does not resolve, then the primary care provider should be immediately notified. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a non-reassuring pattern, then a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. The administration of Pitocin may place additional stress on the fetus.

Maternity nurses often must answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief is accurate? a. Music supplied by the support person must be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D, Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath for as long as they want, although repeated baths with breaks might be more effective than one long bath. Counterpressure can help the woman cope with lower back pain.

Which characteristic of a uterine contraction is not routinely documented? a. Frequency: how often contractions occur b. Intensity: strength of the contraction at its peak c. Resting tone: tension in the uterine muscle d. Appearance: shape and height

ANS: D, Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not routinely charted.