Test 2- OB - Chapter 16

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain."

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first?

Raise the client's legs.

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

The client who is very restless and is moving around in the bed

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?

The fetus is in the true pelvis and engaged.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?

completion of the third stage of labor

When the cervix thins and shortens, it is known as ________________.

effacement

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

T/F: A normal fetal heart rate baseline is between 100 and 170 beats per minute.

false

The ________________ of contractions is timed from the beginning of one contraction to the beginning of the next contraction.

frequency

Which nursing action is required before a client in labor receives an epidural?

giving a fluid bolus of 500 ml

When the membranes of a pregnant client rupture during labor, the nurse determines that the client and fetus are in danger. What did the nurse assess at the time of membrane rupture?

meconium-stained amniotic fluid

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

A ________________ deceleration lasts longer than 2 minutes but less than 10 minutes

prolonged

The most common fetal presentation, when the head is flexed with the chin toward the chest, is called ________________ presentation

vertex

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

infection

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply

- presence of a support partner - low anxiety level - participation in a pregnancy exercise program

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

dilation of the cervix

T/F: An overall contraction pattern can be described by frequency, duration, and intensity of the contractions.

true

T/F: The majority of births take place in a freestanding birthing center.

false

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time."

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

T/F: The urge to push during labor is called the "Franklin reflex".

false

________________ variability occurs when there is an amplitude of 6 to 25 beats per minute in the fetal heart rate.

moderate

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate

A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use?

longitudinal

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia

Which changes in the female body occur to allow the passage of the fetus down the birth canal?

- Vaginal rugae stretch and smooth out. - The cervix dilates to 10 cm. - The cervix softens.

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first."

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4

A nurse is caring for a client in her fourth stage of labor. Which assessment(s) indicates a normal physiologic change occurring during the fourth stage of labor?

- decrease in the pulse rate - decreased intra-abdominal pressure - well-contracted uterus in the midline - mild uterine cramping and shivering

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed?

- determining the lie of the fetus - determining the presentation of the fetus - determining the position of the fetus

A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include?

- internal rotation - descent - flexion

The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus.

1) cramping in the lower abdomen 2) pain in the lower back, buttocks and thighs 3) strong contractions resulting in fetal movement 4) intense burning and stretching pain in the perineum

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

8 to 10

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 seconds

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess the amount of cervical dilation (dilatation).

The nurse is caring for a client entering the active phase of labor. Which outcome is most appropriate at this time?

Client will adjust body to attain the most comfortable position.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

The frequency of the contractions is every 5 minutes.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions.

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?

Use a birthing ball and find a position of comfort.

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point

counterpressure against the sacrum

A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

determine if the client is in true or false labor.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

T/F: The transition phase of labor is the longest stage of labor lasting an average of 12 hours for a primigravida and 8 hours for multigravidas.

false

Which is the most important nursing assessment of the mother during the fourth stage of labor?

hemorrhage

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

increased risk of infection

During active labor, the nurse observes the client crying during contractions and not using breathing techniques learned during prenatal classes. Which client concern is the priority for the nurse to address at this time?

ineffective breathing pattern

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

turn her / ask her to turn on her side.