Saunders- Ch.23: Labor and Birth w/ Rationale

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? 1. Notify the primary health care provider (PHCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

Answer: 1 Rationale: A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

Answer: 1 Rationale: Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

Answer: 1 Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats per minute 3. Maternal pulse rate of 85 beats per minute 4. White blood cell count of 12.000/mm3 (12 × 109/L)

Answer: 2 Rationale: A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of, 11,000-15,000/mm3 (11-15 × 109/L) up to 18,000/mm3 (18 × 109/L) During the immediate postpartum period, the white blood cell count may be 25,000-30,000/mm3 (25-30 × 109/L) because of increased leukocytosis that occurs during delivery.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

Answer: 2 Rationale: Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

Answer: 2 Rationale: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin. 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

Answer: 2 Rationale: The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

Which assessment finding after an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

Answer: 3 Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

Answer: 3, 5 Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The Ferguson reflex is initiated from perineal pressure.

Answer: 3, 5 Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the primary health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

Answer: 4 Rationale: Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

Answer: 4 Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

Answer: 4 Rationale: Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.