The Intraparatum assessment and interventions

15. The obstetric nurse is assessing the laboring patient for pain. Which of the following should the nurse identify in a pain assessment? Select all that apply. 1. Intensity of contractions 2. Presence of pain in the neck or back 3. Frequency and duration of contractions 4. Signs of anxiety 5. Presence of FHR with intermittent auscultation

ANS: 1, 2, 3, 4 In a pain assessment, the nurse should assess for intensity, location, pattern, degree of distress. Fetal heart tones are not part of pain assessment

20. The nurse is helping the patient assume a position for placement of an epidural. Which of the following positions are appropriate for placing an epidural? Select all that apply. 1. Lateral position with head flexed toward chest 2. Trendelenburg position 3. Lithotomy position 4. Sitting position with elbows on knees 5. Prone position

ANS 1,4 The lateral position would give good access to the spine. The sitting position with head flexed would give good access to the spine

13. The nurse is speaking with a pregnant patient who is asking what processes start labor. Which responses by the nurse are appropriate? Select all that apply. 1. There is more pressure on the cervix, which causes the start of contractions by releasing oxytocin. 2. Oxytocin stimulates uterine muscles to contract. 3. The uterus begins to contract due to a decrease in estrogen. 4. The placenta begins to age and deteriorate and this triggers the start of contractions. 5. The fetus releases a stress hormone, cortisol, and this starts contractions

ANS: 1, 2, 4, 5 Increased pressure on the cervix stimulates the nerve plexus, causing release of oxytocin by the maternal pituitary gland, which then stimulates contractions. Oxytocin stimulates uterine muscles to contract. As the placenta ages, it begins to deteriorate, triggering initiation of contractions. Fetal cortisol rises and stimulates the uterus to contract

14. The nurse encourages the patient to bring loved ones to be with her during labor because the nurse knows that their presence does which of the following? Select all that apply. 1. Shortens the length of labor 2. Reduces the likelihood that a patient will require an epidural 3. Reduces the risk of infection after birth 4. Lowers the chance that the patient will breastfeed 5. Increases patients' happiness and satisfaction with the outcome of their birth

ANS: 1, 2, 5 In 2011, the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) found that having support persons shortens labor, found that having support persons decreases the use of analgesia. increased satisfaction with the birth experience in those with support persons. Havin a support person does not have an effect of post-delivery infections, having a support person does increase likelihood of breastfeeding.

16. The nurse educator is teaching the nursing student the basic principles of using analgesia by using a patient, Christa, as an example. Which of the following demonstrates the basic principles of analgesia during Christa's labor and delivery? Select all that apply. 1. Christa has been in labor for 4 hours. She has been having contractions every 3 minutes. Contractions last a minute and are intense. She has had cervical change from 3 to 5 cm over the past 4 hours. 2. The medication Christa wants is an epidural. After she receives the epidural, the FHR tracing is within normal limits. 3. Christa received butorphanol (Stadol) within 3 hours of delivery and the infant experienced neonatal depression. 4. Local anesthesia in the perineal area was used in conjunction with the epidural throughout labor and delivery. 5. Christa has a history of opiate abuse and therefore it was understood that she might require higher doses of medications to experience relief.

ANS: 1, 2, 5 Labor must be well established before administration of an analgesic is begun. Medication should provide relief to the mother with minimal risk to the baby. Women with a history of drug abuse may have a lessened effect from pain medication and require higher doses.

19. The nurse is teaching the patient about the trends and risks of epidural anesthesia. Which of the following should the nurse relay about the risks of epidural anesthesia? Select all that apply. 1. There is a higher rate of instrumental vaginal delivery. 2. When using an epidural, women are less likely to sweat with a fever. 3. There is a higher rate of spontaneous vaginal delivery. 4. Labor may be longer with an epidural. 5. There is a higher rate of fever and sepsis.

ANS: 1, 4, 5 Epidurals are associated with higher rates of forceps and vacuum suction rates as well as longer labor and higher rates of fever and sepsis. An elevation in maternal temperature is associated with regional anesthesia, and it is also associated with reduced perspiration.

18. The nurse educator is teaching about regional and local anesthesia in a childbirth education class. The nurse should teach that regional anesthesia is used for which of the following? Select all that apply. 1. Lidocaine 1% for episiotomy 2. Epidural with lidocaine for pain in labor 3. Spinal block with lidocaine for a cesarean delivery 4. Lidocaine 1% for episiotomy repair 5. Lidocaine without epinephrine for forceps use

ANS: 2, 3, 5 Regional anesthesia can be used for labor pain in the form of a pudendal block, epidural block, or spinal block. Regional anesthesia can be used for surgical pain in cesarean section. A pudendal block (which is regional anesthesia) is used for forceps use

6. The nurse is counseling a 15-year-old pregnant patient at her first prenatal appointment. Which patient teaching by the nurse is appropriate? a. "Adolescents usually have very effective coping mechanisms." b. "Teenagers always have larger babies than older patients." c. "Adolescents' ego integrity is less easily threatened by stress and pain." d. "Your response to pregnancy, labor, and delivery will differ from that of an adult because your cognitive development is not yet complete."

ANS: D According to AWHONN, teenagers have incomplete cognitive development, fewer coping mechanisms than adults, and the ego integrity of adolescents is more easily threatened by stress and pain.

17. A patient is interested in a pain relief option that she can control during labor. The nurse explains to the patient what pain relief options are available that would meet her needs, and they mutually decide on nitrous oxide. Which of the following does the nurse describe to the patient about the use of nitrous oxide in labor? Select all that apply. 1. "If started, it should be used throughout the entire labor." 2. "It has no trade name and is only available in generic forms." 3. "The nurses will administer it to you during every contraction so we will need to be with you during the entire labor." 4. "The gas takes effect in about 50 seconds after the first breath, and the patient will feel calm." 5. "There is no effect on the labor progress from active labor to delivery, and therefore you do not need to worry about longer labors with the medication

ANS: 4, 5 It takes effect in about 50 seconds after the first breath, and the effect is transient. It has no adverse effects on the normal physiology and progress of labor. It is self-administered by the patient, it is called Nitronox, and can be started and stopped.

11. The nurse is caring for a 24-year-old woman who is G1P0 at 40 weeks, 1 day gestation, and in active labor. She has just received an epidural and now complains of "an itchy feeling all over." Her vitals are as follows: HR 120, RR 12, BP 130/74, T 98.8, and O2 sat 98%. Which action should the nurse take first? a. Call the health care provider regarding the patient's pruritus to order an antipruritic medication. b. Activate emergency response due to the patient's pruritus and tachycardia post epidural placement. c. Call the anesthesiologist regarding the patient's oxygen saturation level. d. Take no further action regarding the patient's complaints, as they are normal after epidural placement.

ANS: A Ninety percent of women who receive opioids in epidural have itching, and the health care provider should be notified so the correct medications can be ordered and administered to treat the pruritus.

10. The nurse is caring for a patient in active labor with significant back pain. The patient has requested nonpharmacologic methods of pain relief. The nurse thinks that sterile water injections may help with her pain management. Which of the following explanations should the nurse explain to the patient? a. "We will inject 1 mL of sterile water intramuscularly, and it will last for about an hour." b. "We will inject 0.5 mL of sterile water subcutaneously, and it will last for an hour to 90 minutes." c. "We will inject 1 mL of sterile water subcutaneously, and it will last for about a half hour." d. "We will inject 0.5 mL of sterile water intramuscularly, and it will last for about 3 hours."

ANS: B Sterile water injections are subcutaneous injections of 0.5 ml. and provide 60 to 90 minutes of lower back pain relief.

4. The nurse is reading the patient's chart, which indicates the patient has a "gynaecoid pelvis." What finding is expected in this patient? a. Narrower pubic arch b. Shorter diameter between her coccyx and ischium c. Wider outlet d. Smaller inlet

ANS: C A gynaecoid pelvis has a wider outlet than an android pelvis.

7. The nurse is caring for a 31-year-old female patient who is pregnant at 37 weeks and 5 days gestation. The patient is having contractions every 3 minutes and was found to have a platypelloid pelvis upon examination. The fetus has an estimated fetal weight of 7 lbs and is in the LOA position. This patient is laboring on the birth ball, and her mother-in-law is helping her labor. The nurse is concerned about the five Ps and their effect on the patient's labor. Which P is the nurse most likely concerned about based on the patient's history? a. Passenger b. Position c. Passage d. Psyche

ANS: C A platypelloid pelvis is found in only 3% of women and is not an optimal pelvis for the passage of a vaginal delivery

3. The patient is having an unmedicated childbirth and has begun to bear down. She vocalizes, "The baby is coming!" Which action should the nurse take? a. Help the patient in a lithotomy position. b. Help the patient onto all fours. c. Have the patient assume a comfortable and upright position. d. Help the patient into a knee-chest position

ANS: C An upright position allows gravity to assist with the descent of the baby. Although regularly used, evidence has shown the lithotomy position is not the best position. A knee-chest position does not facilitate birth

The nursing preceptor asks the nursing student how to best determine the intensity of contractions before placing the patient on an electronic fetal monitoring strip. How would the nurse assess this? a. Time the amount of time between the ending of one contraction and the beginning of another. b. Palpate the maternal abdomen right after a contraction ceases. c. Palpate the maternal abdomen during a contraction. d. Monitor the patients' vocalizations and facial expressions.

ANS: C Intensity is evaluated by palpating the fingertips on the maternal abdomen. Timing the amount of time between the ending of one contraction and the beginning of another would determine frequency. Palpating the maternal abdomen right after a contraction ceases would determine resting tone

2. A 40-year-old G5P1031 is attending a childbirth education class. During the class, the woman says, "The worst part of contractions with my last labor was when they were at the peak of intensity." The nurse educator correctly explains that the woman is identifying which part of a contraction? a. When the uterine wall is resistant to indentation b. The longest part of the contraction c. The shortest part of the contraction d. Descending of contraction

ANS: C The acme is the peak of the contraction's intensity but also is the shortest part of the contraction. The longest part of the contraction is the increment, which is the buildup of the contraction. When a nurse palpates moderate contractions, they are resistant to indentation; the acme of a contraction should ideally be strong to palpation.

12. The nurse is reviewing the chart of a 35-year-old G4P2012 woman. The patient is at 38 weeks, 4 days, and is in active labor with SROM clear fluid 2 hours ago. What action should the nurse take? a. Monitor the patient's blood pressure, temperature, and respirations every 2 hours. b. Have the patient rate her pain on a scale from 1-10 roughly every hour. c. Help the patient change her position from side to side every 30 minutes. d. Monitor the fetal heart tones every hour.

ANS: C When the patient is in active labor, the nurse should help the woman change position every 30 minutes and as needed. Once rupture of the membranes has occurred, the nurse should monitor the patient's VS, and temperature every hour. When the patient is in active labor, the nurse should monitor FHR every 15 to 30 minutes.

5. The nurse is caring for a 34-year-old woman who is G2P1001 at 39 weeks and 1 day. The patient is an observant Muslim and is in active labor. Which outcome would be the most effective form of applying culturally sensitive communication? a. Ensuring that the health care provider is present every 2 hours to examine labor progress b. Making sure that the patient has Kosher meat for her postpartum meal c. Making sure that the patient's hair is covered constantly d. Assuring the patient that her baby is less than 9 lbs

ANS: C Modesty is influenced by culture. The others may affect the psyche of the patient, but it is not usually related specifically to culture.

8. The patient is a 26-year-old G1P0 at 38 weeks, 2 days of gestation. She is at her provider's office for a visit and complains to the nurse of wrist pain, fatigue, increased discharge, and "feeling heavy." Which complaint could be a sign of impending labor? a. Wrist pain b. Fatigue c. Increased discharge d. Heavy feeling

ANS: C When labor is impending, the patient may lose her mucous plug or have a change in discharge. Fatigue, wrist pain, and heavy feeling is common in pregnancy but is not a sign of impending

9. The nurse educator is in a childbirth education class discussing nonpharmacological ways nurses can assist to enhance labor and spontaneous vaginal delivery. Which of the following facts regarding nonpharmacologic approaches will the nurse use to help illustrate its benefits? a. Using peppermint aromatherapy oils will help promote relaxation. b. The client can achieve self-hypnosis with the Bradley Method. c. Sterile water injections can be very useful for pelvic pain. d. Effleurage is performed in rhythm with breathing during a contraction

ANS: D Effleurage is cutaneous stimulation by lightly stroking the maternal abdomen in rhythm with breathing during contractions. Although aromatherapy is a nonpharmacologic method of promoting relaxation and decreasing pain perception, peppermint is used to help with nausea, not to enhance labor and spontaneous vaginal delivery. Sterile water injections are used for lower back pain relief.