PrepU Query Quiz: Labor and Delivery

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

Reducing visual and auditory stimulation A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although monitoring the client's labor, preparing for a fast delivery, assessing the fetal tracing, and checking vital signs are important actions, they're lower priorities than reducing stimulation.

When caring for a client who's a primigravida, the nurse should expect that the second stage of labor to last: a) 3 hours b) 4 hours c) 1 hour d) 2 hours

1 hour The average length of time of the second stage of labor for a primigravida is 1 hour. Longer than 1 hour might mean the client is experiencing an arrest in descent.

A nurse is caring for a primigravida client. At 20 weeks of gestation, identify the location where the nurse anticipates the uterine fundus.

At 20 weeks, the uterine fundus would be palpated approximately at the umbilicus. Fundal height would be measured from the symphysis pubis to the top of the uterus (McDonald's method). Serial measurements assess fetal growth over the course of the pregnancy. Between weeks 22 and 34, the number of centimeters measured correlate approximately with the week of gestation. However, if the client is very tall or short, fundal height will differ.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? a) Dilation, effacement, position b) Dilation, duration, and frequency c) Duration, frequency, and intensity d) Frequency, duration, maternal position

Duration, frequency, and intensity The nurse should document the duration, frequency, and intensity of uterine contractions. Dilation refers to the number of centimeters the cervix is dilated; it doesn't describe uterine contractions. Maternal position doesn't help describe uterine contractions. Dilation and effacement both refer to the condition of the cervix, not uterine contractions.

When reviewing a fetal monitor strip, the nurse looks for reassuring and nonreassuring fetal heart rate (FHR) patterns. Which pattern is abnormal? a) Variable FHR pattern that begins and ends abruptly b) FHR that accelerates to baseline tachycardia c) Variability that doesn't decrease d) Baseline FHR that doesn't increase

FHR that accelerates to baseline tachycardia In an abnormal pattern, the FHR accelerates to baseline tachycardia as the fetus attempts to compensate for a growing oxygen deficit. A normal variable pattern has an abrupt onset and end. The baseline FHR doesn't increase and short-term variability doesn't decrease.

A client in labor is 8 cm dilated. The fetus, which is in vertex presentation, is 75% effaced and is at 0 station. In the illustration, identify the level of the fetus's head.

Station refers to the level of the presenting part in relation to the pelvic inlet and the ischial spines. A 0 station indicates that the presenting part lies at the level of the ischial spines. Other stations are defined by their distance in centimeters above or below the ischial spines.

Which finding is the most serious adverse effect associated with oxytocin administration during labor? a) Water intoxication b) Elevated blood pressure c) Tetanic contractions d) Early decelerations of fetal heart rate

Tetanic contractions Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered. This drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.

A client's labor doesn't progress. After ruling out cephalopelvic disproportion, the physician orders I.V. administration of 1,000 ml normal saline solution with 10 units of oxytocin to run at 2 milliunits/minute. Two milliunits/minute is equivalent to how many milliliters per minute? a) 0.02 b) 0.2 c) 0.002 d) 2

0.2 Each unit of oxytocin contains 1,000 milliunits. Therefore, 1,000 ml of I.V. fluid contains 10,000 milliunits (10 units) of oxytocin. To determine milliliters per minute, set up a ratio and perform the calculation as shown:

A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. Her latent phase may be considered prolonged after: a) 6 hours. b) 14 hours. c) 10 hours. d) 20 hours.

10 hours. Based on research, the latent phase may be considered prolonged if it exceeds 9 hours in a nulliparous client or 6 hours in a multiparous client.

Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin. Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration? a) Oxytocin is toxic to the kidneys. b) Oxytocin has a diuretic effect. c) Oxytocin causes water intoxication. d) Oxytocin causes excessive thirst.

Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

A client in labor has an episiotomy. The nurse understands that the client is at risk for which complication? a) Uterine disfiguement b) Hormonal fluctuations postpartum c) Prolonged dyspareunia d) Blood loss

Prolonged dyspareunia Prolonged dyspareunia (painful intercourse) may occur if infection interferes with healing of the episiotomy site. Minimal blood loss occurs when an episiotomy is performed. The uterus isn't affected by episiotomy. The procedure involves cutting the perineum to accommodate the fetus. An episiotomy doesn't influence the hormonal fluctuation that occurs during the postpartum period.

A client in labor is given 25 mg of intravenous (IV) meperidine for labor pain. The nurse should monitor the client for which adverse effects of the drug? Select all that apply. a) Hypertension b) Tachycardia c) Respiratory depression d) Urinary incontinence e) Nausea and vomiting

• Nausea and vomiting • Respiratory depression • Tachycardia Adverse effects of meperidine include hypotension (not hypertension), nausea, vomiting, respiratory depression, urinary retention (not urinary incontinence), tachycardia, sedation, drowsiness, and decreased uterine activity.

When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be: a) a length of time that can't be determined based on her first labor. b) about half as long as her first labor. c) shorter than her first labor. d) about the same length of time as her first labor.

About half as long as her first labor. A woman having her second baby can anticipate a labor about half as long as her first labor.

A physician decides to artificially rupture a client's membranes. After this procedure, the nurse checks the fetal heart tones to: a) prepare for an imminent delivery. b) determine fetal well-being. c) assess for fetal bradycardia. d) assess fetal position.

Assess for fetal bradycardia. After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

A nurse is teaching a primipara and her partner about the labor and birth process. The nurse describes the maneuvers that the fetus goes through during the labor process when the head is the presenting part. Place the maneuvers below in the order in which the nurse should explain that they occur. All options must be used. 1 internal rotation 2 engagement 3 descent 4 flexion

Engagement Descent Flexion Internal rotation Engagement describes when the fetus enters the true pelvis; it occurs before descent in primiparas and concurrently in multiparous women. If the head is the presenting part, after engagement occurs, the normal order of maneuvers (cardinal movements) during labor and birth is descent, flexion, internal rotation, extension, external rotation, and expulsion. They occur as the fetal head passes through the maternal pelvis during the normal labor process.

During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority? a) Ineffective fetal cerebral tissue perfusion related to cord compression b) Risk for infection related to rupture of membranes c) Deficient knowledge (testing procedure) related to amniotomy d) Acute pain related to increasing strength of contractions

Ineffective fetal cerebral tissue perfusion related to cord compression Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Acute pain, and Risk for infection.

A client is at risk for which postpartum complication during the fourth stage of labor? Select all that apply. a) Arrhythmias b) Hemorrhage c) Postpartum depression d) Infection e) Mastitis

Hemorrhage The fourth stage of labor involves the first 2 hours after birth. During this stage, the mother and neonate adjust physiologically to the birth, and the mother is at risk for hemorrhage. Arrhythmias are not typical, but heart rate decreases to 50 to 70 beats/minute. Infection, mastitis, and postpartum depression are complications that may occur later in the postpartum period.

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

Assess the frequency of uterine contractions. Before administering prostaglandin E2 gel, the nurse would assess the frequency and duration of any uterine contractions first because prostaglandin E2 gel is contraindicated if the client is having contractions. If there are no contractions, the client should be placed in a semi-Fowler's position to allow for vaginal insertion of the gel. Although determining whether the client's membranes have ruptured is part of the assessment of any client in labor, it is not specifically related to the administration of prostaglandin E2 gel. If the membranes remain intact, an amniotomy may be performed once the client begins to dilate and the fetal head is engaged. However, it is not necessary for the nurse to prepare the client for this procedure at this time.

After teaching a woman who is in labor about the purpose of the episiotomy, which purpose stated by the client would indicate to the nurse that the teaching was effective? a) prevents perineal edema b) enlarges the pelvic inlet c) ensures quick placental delivery d) assists with birth of a large baby

Assists with birth of a large baby Once routine, episiotomies are now only performed if the baby's head or shoulders are too large for the mother's vaginal opening or during the vaginal birth of a breech baby. An episiotomy may help prevent tearing of the rectum, but it does not necessarily relieve pressure on the rectum. Tearing may still occur. An episiotomy has no effect on the pelvic inlet. An episiotomy does not prevent perineal edema. Rather it helps to reduce the risk of tearing of the perineal tissues. An episiotomy does not ensure quick delivery of the placenta. Delivery of the placenta should occur within 30 minutes, regardless of whether an episiotomy has been performed.

While caring for a postterm multigravida who is being induced with intravenous oxytocin solution, what finding should the nurse interpret as indicative of a possible complication? a) hypotension b) generalized edema c) depressed deep tendon reflexes d) convulsions

Convulsions Severe water intoxication with convulsions and coma can occur when clients are induced with oxytocin. Other serious adverse effects include hypertension, uterine rupture, tetanic contractions, neonatal jaundice, and postpartum hemorrhage. Generalized edema is not a complication of administering oxytocin. Depression of deep tendon reflexes is a possible complication of magnesium sulfate therapy. Hypertension, rather than hypotension, may be a complication of oxytocin.

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

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

A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which position so the client can begin pushing? a) side-lying while keeping the head elevated b) squatting with the back arched c) squatting with the body curved in a C shape d) in the knee-chest position while keeping the head down

Squatting with the body curved in a C shape Anatomically, the squatting position enlarges the pelvic outlet and uses the force of gravity during pushing. The mother should curve her body into a C shape for the greatest effectiveness.

To obtain the obstetric conjugate measurement, the nurse would do which of the following? a) Subtract 1.5 to 2 cm from the diagonal conjugate. b) Add 1.5 cm to the transverse diameter. c) Measure the diameter of the pelvic inlet. d) First measure the angle of the pubic arch.

Subtract 1.5 to 2 cm from the diagonal conjugate. The obstetric conjugate can be estimated by subtracting 1.5 to 2 cm from the diagonal conjugate, which can be measured during a pelvic examination. Transverse diameters of the pelvic inlet are not measured and the pubic arch has no relevance to the obstetrical conjugate.

A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which statement should the nurse include in the teaching plan about pushing? a) Pushing is most effective when the client holds her breath. b) The client should be urged to push with an open glottis. c) The client needs to push for at least 1 to 3 minutes. d) Pushing is limited to times when she feels the urge.

The client should be urged to push with an open glottis. The client should be urged to push with an open glottis to prevent the Valsalva maneuver. Pushing with a closed glottis increases intrathoracic pressure, preventing venous return. Blood pressure also falls, and cardiac output decreases. Pushing for at least 1 to 3 minutes is too long; prolonged pushing can lead to reduced blood flow and fatigue. Pushing for the duration of the contraction is sufficient. Pushing while holding the breath results in the Valsalva maneuver. Because the client has had an epidural anesthetic, she may not feel the urge to push and may need coaching during the pushing phase.

The nurse is assisting with birth to a multigravida in active labor who is not having anesthesia. The, client's cervix is completely dilated. The nurse should assist the client to deliver the fetal head by pushing: a) between contractions. b) near the end of a contraction. c) when she has an urge to push. d) as soon as a contraction begins.

When she has an urge to push. The best approach is to allow the client to push when she feels the urge to push with a contraction. When the contraction begins, the client may have an immediate urge to push, or it may take time for fetal descent to stimulate stretch receptors. Urging the client to push before she feels the urge may needlessly tire her. Pushing at the end of a contraction or between contractions is not as effective as pushing when the client feels the urge. Additionally, clients should rest between contractions.

An emergency cesarean birth is planned for a pregnant client who begins to experience excessive vaginal bleeding soon after admission. When developing this client's plan of care, which action would be the priority? a) Assess the status of the fetus. b) Ask family members to wait in the waiting room. c) Shave the abdomen and perineal area. d) Ensure availability of replacement blood.

Ensure availability of replacement blood. A cesarean birth is considered major surgery. Thus, before any type of major surgery, the nurse should be certain that blood replacement therapy is available should any complications occur involving hemorrhage. The client is also at high risk for hypovolemic shock due to the excessive vaginal bleeding. Shaving the abdomen and perineal area may be required, but this is not the priority at this time. Because the client is experiencing excessive vaginal bleeding, she is at greatest risk for hypovolemic shock necessitating blood replacement. Family members can be supportive and should be allowed to stay with the client if the client desires. Assessing the status of the fetus is important, but this can be accomplished once the availability of blood replacement has been confirmed.

A primigravid client in active labor whose cervix is dilated to 5 cm and completely effaced is using the Lamaze method of prepared childbirth during labor. The client has been using slow-paced breathing and tells the nurse that this does not appear to be helping her during a contraction. The nurse should suggest to the client that she use which technique? a) modified-pace breathing b) deep abdominal breathing c) pant-and-blow breathing d) open-glottis breathing

Modified-pace breathing With time, habituation may occur, making slow-paced breathing less effective. The nurse should suggest to the client that she switch to modified-pace breathing, which is performed as an upper chest breath either through nose or mouth. A commonly taught method is three breaths, then a soft blow. Deep abdominal breathing is primarily useful in early labor. Pant-and-blow breathing typically is useful during the transition stage. Open-glottis breathing is useful for the second stage of labor and the birth process.

A primigravid client is admitted as an outpatient for an external cephalic version. Which factor would be a contraindication for the procedure? a) maternal Rh-negative blood type b) breech presentation c) history of gestational diabetes d) multiple gestation

Multiple gestation External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent the need for a cesarean birth. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie. Contraindications to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, severe oligohydramnios (decreased amniotic fluid), contraindications to a vaginal birth (e.g., cephalopelvic disproportion), and unexplained third trimester bleeding. If the mother has Rh-negative blood type, the procedure can be performed and Rh immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational diabetes is not a contraindication unless the fetus is large for gestational age and the client has cephalopelvic disproportion.

Question: After several hours of induction with intravenous oxytocin administered along with a primary intravenous solution of lactated Ringer's solution, assessment of a primigravida at 42 weeks' gestation reveals a fetal heart rate near the baseline at 120 bpm and strong contractions occurring every 2 to 2.5 minutes and lasting 90 to 100 seconds. In what order from first to last should the nurse perform the required actions? All options must be used. 1. Administer oxygen at a rate of 8 to 10 L/min. 2. Contact the primary care provider for further prescriptions. 3. Position the client in a lateral position. 4. Stop the intravenous flow of oxytocin.

1. Stop the intravenous flow of oxytocin. 2. Position the client in a lateral position. 3. Administer oxygen at a rate of 8 to 10 L/min. 4. Contact the primary care provider for further prescriptions. The nurse first should stop the intravenous flow of oxytocin because the client is exhibiting a hypertonic uterine contraction pattern caused by the oxytocin. Once the oxytocin infusion is stopped, the nurse should place the client in a lateral position to improve placental blood flow to the fetus. The nurse should next administer oxygen, and then contact the primary care provider to report the situation and obtain further prescriptions.

To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which cranial sutures? a) coronal b) sagittal c) frontal d) lambdoidal

Sagittal The sagittal suture is the most readily felt during a vaginal examination. When the fetus is in the LOA position, the occiput faces the mother's left. The lambdoid suture is on the side of the skull. The coronal suture is a horizontal suture across the front portion of the fetal skull that forms the anterior fontanel. It may be felt with a brow presentation. The frontal suture may be felt with a brow or face presentation.

A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage? Select all that apply. a) The client is apprehensive about the process. b) The client states she has discomfort from uterine contractions. c) The client is feeling embarrassed as she has an urge to defecate. d) The client is focused on the neonate's condition. e) The client is exhausted from the labor process. f) The client is excited about the process.

• The client is focused on the neonate's condition. • The client states she has discomfort from uterine contractions. In the third stage of labor, the client focuses on the neonate's condition. Before the placenta is expelled, she may also state that she is experiencing discomfort from uterine contractions. Excitement and apprehension are characteristic of the first stage of labor. Exhaustion is common in the second stage of labor. The urge to defecate is noted prior to birth at the end of the second stage of labor when the fetus is pushing on the rectum.

Assessment of a primigravida in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What should the nurse do when the primary care provider prescribes meperidine 50 mg intramuscular (IM) for the client? a) Be certain that naloxone is at the client's bedside. b) Administer the medication in the left ventrogluteal muscle. c) Refuse to administer the medication to the client. d) Ask the primary care provider to validate the dosage of the drug.

Refuse to administer the medication to the client. The nurse should refuse to administer the medication to the client because of the risk of respiratory depression in the neonate. Meperidine, given IM, peaks in 30 to 60 minutes and lasts 2 to 4 hours. Based on the assessment findings, the client most likely will be giving birth within that time frame, increasing the risk for respiratory depression in the neonate, a serious consequence. Therefore, the nurse should not administer the drug. Naloxone should be readily available whenever narcotics that can result in respiratory depression are used. Asking the primary care provider to validate the dosage is not necessary. For clients in early labor, meperidine can be given IM in dosages ranging from 50 to 100 mg.

A primigravid client is experiencing a prolonged second stage of labor with a fetus suspected of weighing more than 4 kg. Which intervention is most important? a) administering an IV fluid bolus b) preparing for a vacuum-assisted delivery c) performing the McRoberts maneuver d) preparing for an emergency cesarean birth

Performing the McRoberts maneuver A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at birth. Immediate nursing actions for a shoulder dystocia include suprapubic pressure and the McRoberts maneuver. If after interventions for vaginal birth with a shoulder dystocia fail, an emergency cesarean birth may be needed but is not indicated at this time. A vacuum-assisted birth would be contraindicated due to increased risk of shoulder dystocia with a macrosomic infant. An IV fluid bolus may be indicated for fetal distress, but there is not enough information to establish that they are needed at this time.

A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? a) Chest panting b) Deep breathing c) Deep, cleansing breaths d) Shallow chest breathing

Shallow chest breathing Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.

A laboring client brings a doula with her to the labor room. When working with the doula, which of the following actions can a doula perform with a laboring client? Select all that apply. a) Perform vaginal examinations and abdominal assessment during labor b) Time contractions c) Make decisions for a client in labor d) Serve as a support person and coach during labor e) Function as a resource person in the perinatal time

• Serve as a support person and coach during labor • Function as a resource person in the perinatal time The role of the doula in labor and birth is to provide support. Doulas do not assist with the birth process and do not replace the husband or partner. Doulas are not certified to perform vaginal exams or abdominal assessments. Doulas are to provide physical, emotional, and informational support for the woman and family, but do not make decisions for clients.

The nurse admits a multigravida in active labor to the birthing center. The client has had no prenatal care with this pregnancy. The nurse determines that the client's cervix is 9 cm dilated, completely effaced, and 0 station with a face presentation. After explaining to the client about face presentations, the nurse determines that the client understands the issues associated with face presentation when she says: a) "Babies who are past their due date may have a face presentation." b) "Face presentation is associated with a small maternal pelvis." c) "Face presentation is associated with abruptio placentae." d) "If the baby's chin is facing my back, a vaginal birth is likely."

"Face presentation is associated with a small maternal pelvis." Face presentations are associated with a small or contracted maternal pelvis. It may occur with the relaxed uterus of a multigravida, prematurity, hydramnios, or placenta previa. Face presentations are associated with placenta previa, not abruptio placentae. Face presentations are associated with prematurity, not prolonged gestation. If the fetal chin is posterior, a cesarean section is warranted because uterine dysfunction or transverse arrest may occur.

Assessment of a primigravida in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at +1 station. The client has indicated that she wants a "natural childbirth" with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The primary care provider enters the room and tells the client that it is time for an epidural anesthetic. The nurse should next: a) ask the client if she desires an epidural anesthetic. b) ask the client to discuss this with her husband and then make a decision. c) tell the client that her labor will be more comfortable with an anesthetic. d) tell the primary care provider that the client desires a "natural childbirth."

Ask the client if she desires an epidural anesthetic. Explanation: To be a true client advocate, the nurse should ask the client if she desires an epidural anesthetic even though the client has indicated a desire for "natural childbirth." The client has a right to change her mind and also a right to refuse treatment. The client, not the nurse, should be the one to tell the primary care provider that she does not want an epidural anesthetic; the nurse should support the client's decision. Although telling the client that her labor will be more comfortable with an anesthetic provides the client with information, a statement such as this can be viewed as an attempt to change the client's mind. The client may wish to discuss this situation with her husband, but she does not have to do so.

The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess: a) bladder status. b) fetal heart rate variability. c) status of membranes. d) cervical dilation again.

Bladder status. The bladder status should be monitored throughout the labor process, but especially before the client begins pushing. A full bladder can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that the client is receiving intravenous fluids, contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and fetal heart rate variability throughout labor, this does not affect the client's ability to push. There is no need to recheck cervical dilation because increasing the frequency of examinations can increase the client's risk for infection.

The nurse has received a telephone call from the emergency department indicating that a multigravid client in early labor and diagnosed with probable placenta previa will be arriving soon. What is the priority invention when the client arrives at the unit? a) whole blood replacement b) continuous blood pressure monitoring c) immediate cesarean birth d) internal fetal heart rate monitoring

Continuous blood pressure monitoring For a client diagnosed with probable placenta previa, hypovolemic shock is a complication. Continuous blood pressure monitoring with an electronic cuff is the priority assessment after the client's admission. Once the client is admitted, an ultrasound examination will be performed to determine the placement of the placenta. Whole blood replacement is not warranted at this time. However, it may be necessary if the client demonstrates signs and symptoms of hemorrhage or shock. Internal fetal heart rate monitoring is contraindicated because the monitoring device may puncture the placenta and place both the mother and fetus in jeopardy. An immediate cesarean birth is not necessary until there has been an assessment of the amount of bleeding and the location of the placenta previa.

A multigravid client in active labor at term is diagnosed with polyhydramnios. The health care provider (HCP) has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which problem in the fetus or neonate? a) gastrointestinal disorders b) intrauterine growth restriction c) renal dysfunction d) pulmonary hypoplasia

Gastrointestinal disorders Polyhydramnios is an abnormally large amount of amniotic fluid in the uterus. The client has understood the instructions when the client states that polyhydramnios is associated with gastrointestinal disorders (e.g., tracheoesophageal fistula). Polyhydramnios is also associated with maternal illnesses such as diabetes and anemia. Other fetal/neonatal disorders associated with this condition include congenital anomalies of the central nervous system (e.g., anencephaly), upper gastrointestinal obstruction, and macrosomia. Polyhydramnios can lead to preterm labor, premature rupture of the membranes, and cord prolapse. Renal dysfunction and intrauterine growth restriction are associated with oligohydramnios, not polyhydramnios. Pulmonary hypoplasia (poorly developed lungs) is associated with prolonged oligohydramnios.

The client presents to the labor and child-birth unit stating pain radiating from the back to the abdomen. Contractions are noted on the fetal monitor varying between every 8 to 10 minutes. Accelerations with movement and moderate variability notes. The fetal heart rate is 120 BPM. Client verbalizes a 6 on the 0-10 pain scale during contractions. Contractions. Membranes intact. Cervical dilation 4 cm. Health care provider notified---- S. Brown, RN A primigravida client arrives at the labor and childbirth unit at 39 weeks gestation. Once completing the initial assessment, the nurse documents the note above. Which nursing action is initiated? a) Preparing the client for a cesarean section. b) Admitting the client to the labor and childbirth unit. c) Providing discharge home with instruction to ambulate. d) Instructing the client to rest and turn on the left side.

Providing discharge home with instruction to ambulate. The nurse identifies the client as being in early labor by symptoms of back pain, varying contractions, moderate pain, and cervical dilation of 4 cm. The nurse identifies the normal progress of labor thus far and conveys to the health care provider. Until the health care provider admits the client, it is appropriate to have the client discharged with instruction to ambulate. Typically the client is instructed to return to the birthing center/hospital when contractions are 4-5 minutes apart. Ambulation may progress the labor process. The client does not need to turn on her left side as there is no sign of fetal compromise. The client is considered a full term pregnancy. There is no indication of a need for a cesarean section.

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor? a) focusing on an object in the room during the contractions b) relaxing uninvolved body muscles during uterine contractions c) practicing being in a deep, meditative, sleeplike state d) breathing rapidly and deeply between contractions

Relaxing uninvolved body muscles during uterine contractions Childbirth educators use various techniques and methods to prepare parents for labor and birth. Active relaxation involves relaxing uninvolved muscle groups while contracting a specific group and using chest breathing techniques to lift the diaphragm off the contracting uterus. A deep, meditative, sleeplike state is a form of passive relaxation. Focusing on an object in the room is part of Lamaze technique for distraction. Breathing rapidly and deeply can lead to hyperventilation and is not recommended.

A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. This color indicates: a) amniotic fluid embolism. b) Rh sensitization. c) oligohydramnios. d) abnormal presentation.

Rh sensitization. Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid. In an abnormal presentation, in this case a breech presentation, it is not uncommon for the amniotic fluid to be green in color owing to meconium expelled by the fetus. Amniotic fluid embolism is not related to the fluid color. This condition, a medical emergency, may occur naturally after a difficult labor or from hyperstimulation of the uterus. Oligohydramnios refers to a markedly decreased volume of amniotic fluid. It has no association with the color of the fluid.

A client is a primigravida in early labor. She tells the nurse that she is worried about pain control as her contractions are becoming stronger, and she asks the nurse about the use of narcotics. Which of the following is the nurse's appropriate response about the use of narcotics? Select all that apply. a) "Narcotics will require that the newborn is given naloxone upon birth." b) "Narcotics are very effective in early labor." c) "Narcotics may prolong labor if given too early." d) "Narcotics can decrease uterine activity." e) "Narcotics cause variable fetal heart rate accelerations."

• "Narcotics can decrease uterine activity." • "Narcotics may prolong labor if given too early." Narcotics may decrease uterine activity if given in early labor, thus slowing the progression of labor. Narcotics may cause decreased fetal heart rate variability. If the newborn experiences respiratory depression upon birth, naloxone may be warranted; however, this is not always required and other interventions may be appropriate.

A nurse is assigned to assist with the admission of a laboring client. Which of the following actions are appropriate? Select all that apply. a) Taking maternal and fetal vital signs. b) Asking about the amount of time between contractions. c) Asking about the estimated date of childbirth. d) Administering an analgesic. e) Estimating fetal size. f) Asking about the woman's last menses.

• Asking about the estimated date of childbirth. • Taking maternal and fetal vital signs. • Asking about the amount of time between contractions. The nurse should ask about the estimated date of childbirth and then compare the response to the information in the prenatal record. If the fetus is preterm, special precautions and equipment are necessary. Maternal and fetal vital signs should be obtained to evaluate the well-being of the client and fetus. Determining how far apart the contractions are provides the health care team with valuable baseline information. The physician estimates the size of the fetus. It would not be appropriate for the nurse to ask about the client's last menses. This information is collected at the first prenatal visit. It would be premature to administer an analgesic, which could slow or stop labor contractions.

The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The multigravida client is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next ten minutes with the client? Select all that apply. a) Determine support systems for the client. b) Prepare to give an early report to the nurse arriving on the next shift. c) Call other staff to set up the birthing table. d) Begin fetal monitoring. e) Assess comfort needs of the client.

• Begin fetal monitoring. • Call other staff to set up the birthing table. • Assess comfort needs of the client. • Determine support systems for the client. Assuring the safety of this client is the top priority. The nurse should begin either intermittent or continuous fetal and contraction monitor depending on the client's risk status. Since the client is 8 cm dilated and a multigravid client, asking other staff members to set up the birthing table would be in order. This client is not a candidate for medication as this may have an influence on the baby. This client is past the point of offering an epidural as she may have given birth by the time the medication is in effect, but comfort measures such as warm or cool cloths, back rubs, etc. may be helpful. The support system is an important aspect of the birthing process and is an easily settled situation. Preparing to give an early report to the oncoming nurse does not apply in this situation.

A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block? Select all that apply. a) Make sure oxygen is available. b) Monitor fetal heart rate and contractions closely. c) Maintain intravenous (IV) fluid at a keep-vein-open rate. d) Keep the client positioned on her left side. e) Monitor vital signs frequently.

• Make sure oxygen is available. • Monitor fetal heart rate and contractions closely. • Monitor vital signs frequently. The nurse should make sure that oxygen is available in case hypotension occurs. IV fluid should be infusing to prevent dehydration, which might cause hypotension. The client should be positioned on her side and her position should be alternated from side to side every 30 to 60 minutes. Fetal heart rate and contractions must be monitored closely, because the client may be unaware of changes in the strength of contractions or the descent of the presenting part.

A primigravida experiences spontaneous rupture of the membranes. What should the nurse do? Select all that apply. a) Assess maternal temperature. b) Tell the client that birth will most likely occur within the next hour. c) Perform a nitrazine test to confirm that the membranes are ruptured. d) Prepare the client for childbirth. e) Monitor the fetal heart rate and pattern.

• Perform a nitrazine test to confirm that the membranes are ruptured. • Monitor the fetal heart rate and pattern. • Assess maternal temperature. When membranes rupture, the nurse should immediately check fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. He or she should also perform a nitrazine test to confirm that the membranes are ruptured. Maternal temperature should be assessed every 1 to 2 hours so infection can be identified early. Membranes may rupture any time during labor. In some cases, 24 hours may pass between rupture and onset of labor, so the nurse does not need to prepare for childbirth at this time.