Unit 2
It was once thought that an episiotomy made the birth less painful and heal faster than a spontaneous laceration of the perineum. Research has not shown these assumptions to be true. What is another finding in the research on episiotomies? causes loss of bowel control after the birth increases the risk of blood loss immediately after delivery suturing of episiotomy increases sexual pleasure following delivery. decreases risk of infection after delivery
increases the risk of blood loss immediately after delivery
The nursing instructor is conducting a class presenting the various aspects of a cesarean birth. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication? laceration of the uterine artery thrombosis infection pneumonia
infection
As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? kangaroo care koala care providing pain relief for the mother making sure the significant other holds the infant shortly after birth
kangaroo care
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 0 -5 +1
+4
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions cause "ripening" of the cervix. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions get closer together with activity. Braxton Hicks contractions do not last long enough to be true labor.
Braxton Hicks contractions usually decrease in intensity with walking.
A 21-year-old has been in labor for 4 hours; her examination 2 hours ago revealed 6 cm/100%/-3. During a contraction, she spontaneously ruptures her membranes. The doctor checks the patient, finds her to be 9 cm/100%/-3, and states that the cord is palpable. What should the nurse do? Set up for imminent vacuum delivery. Set up for imminent forceps delivery. Call the pediatricians into the room for imminent vaginal delivery. Call for help and prepare the client for an emergency cesarean birth.
Call for help and prepare the client for an emergency cesarean birth.
Which fetal adaptation is anticipated in a vaginal birth? Select all that apply. Changing heart rate during contractions Decreasing pH throughout labor Circumoral cyanosis after birth Decreased intracranial pressure Excretion of respiratory tract mucus
Decreasing pH throughout labor Changing heart rate during contractions Excretion of respiratory tract mucus
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? Difficulty breathing Staggering gait Decreased level of consciousness Intense pain
Difficulty breathing
A client in labor receiving epidural anesthesia develops hypotension. What would the nurse do first? Give an intravenous bolus of fluid. Call the anesthesiologist immediately. Inject ephedrine immediately. Inject propranolol immediately.
Give an intravenous bolus of fluid.
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? Assist the client to a Fowler position. Have the client lightly push to meet the need. Have the client pant and blow through the contraction. Have the client divert the energy to squeezing a hand.
Have the client pant and blow through the contraction.
In providing culturally competent care to a laboring woman, which is a priority? Identify the decision maker within the family. Identify any cultural foods used prior to labor. Identify who is the support person during the labor. Identify how the client expresses labor pain.
Identify how the client expresses labor pain.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Radiates from the back to the front Occurs in an irregular pattern Slows when the woman changes position Lasts about 20 to 25 seconds
Radiates from the back to the front
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 client is fully effaced. The fetus is in the true pelvis and engaged. The fetus is floating high in the pelvis. The fetus has descended down the birth canal.
The fetus is in the true pelvis and engaged.
A woman having a cesarean birth will have a low transverse incision ("bikini cut"). Which of the following would the nurse cite as an advantage? The uterine incision will be vertical. Because the fundus of the uterus is cut, the infant can be resuscitated rapidly. The skin incision will be just above her pubic hair. Because the cervix is cut, the operation proceeds rapidly.
The skin incision will be just above her pubic hair.
A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: yellow. olive green. blue. pink.
blue
A nurse notes the digital readings of the electronic fetal monitor show decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus? genitourinary system musculoskeletal system central nervous system (CNS) gastrointestinal system
central nervous system (CNS)
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur? cervical ripening and softening bloody show Braxton Hicks contractions lightening
cervical ripening and softening
A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? poorly ossified bones of the cranial vault well-ossified bones of the face rigid bones at the base of the skull tight membranous attachments
poorly ossified bones of the cranial vault
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes? another cause other than the birth postpartum hemorrhage normal for a cesarean section infection
postpartum hemorrhage
During the second stage of labor, a woman is generally: anxious to have people around her. very aware of activities immediately around her. no longer in need of a support person. turning inward to concentrate on body sensations.
turning inward to concentrate on body sensations.
A client is being prepared for a scheduled cesarean birth by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post-cesarean birth? administration of sodium citrate urinary output preparing for blood transfusion maintaining IV access
urinary output
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? Wait 2 minutes to review another tracing. Assess and reposition the woman. Notify the health care provider. Notify the registered nurse.
Assess and reposition the woman.
How does a woman who feels in control of the situation during labor influence her pain? Feelings of control are inversely related to the client's report of pain. Feeling in control shortens the overall length of labor. There is no association between the two factors. Decreased feeling of control helps during the third stage.
Feelings of control are inversely related to the client's report of pain.
A client who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the client's fluid status during the procedure? Administer an antiemetic as prescribed. Provide a clear liquid tray. Initiate intravenous fluid therapy. Encourage intake with ice chips.
Initiate intravenous fluid therapy.
Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? increased intracranial pressure vaginal lacerations scalp edema cervical lacerations
scalp edema
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? Assess for dry mouth. Assess for constipation. Assess maternal blood pressure. Assess fetal heart rate.
Assess fetal heart rate.
The nurse is preparing a client in labor to receive a pudendal block with lidocaine. The nurse would place the client in which position for administration? lithotomy Trendelenburg left lateral prone
lithotomy
A woman whose fetus at 30 weeks' gestation is failing to thrive in utero is told her physician wants to deliver the baby by cesarean birth today. She asks the nurse why this would be preferred to a vaginal birth. Which of the following would be your best response? "Cesarean birth will reduce pressure on the immature head." "There's not an advantage; it's just more convenient." "Cesarean birth allows the placenta to deliver easier." "You will have reduced pain afterward."
"Cesarean birth will reduce pressure on the immature head."
A 35-year-old P1001 has been admitted for a scheduled repeat cesarean. As the nurse prepares the client for surgery, what is the best way to begin preoperative teaching? Start by going over the risks of cesarean so she has enough time to go over each one. Wait until the physician and the anesthesiologist have completed their history and assessment, so the teaching can be more focused and directed. Assess how much the woman already knows about cesarean. Ask her husband, who is fearful and anxious, to wait outside.
Assess how much the woman already knows about cesarean.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Effacement time and time when contractions are regular Admission time and time of fetal birth Complete cervical dilation (dilatation) and time of fetal birth Time of mucus plug expulsion and full cervical dilation
Complete cervical dilation (dilatation) and time of fetal birth
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal request for pain medication Maternal heart rate and blood pressure Fetal heart rate in relation to contractions The station in which the fetus is located
Fetal heart rate in relation to contractions
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal position Fetal lie Fetal presentation Fetal attitude
Fetal lie
Elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor? Induced labor decreases the possibility of cesarean birth. Induced labor decreases the need for interventions during labor and delivery. Induced labors are less painful and progress faster. Induced labor can result in higher costs for the delivery.
Induced labor can result in higher costs for the delivery.
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Rubbing the client's legs Placing a wedge under the hips Massaging the client's lower back Providing a paper bag
Placing a wedge under the hips
During which phase of labor would the nurse anticipate providing the most emotional support for the mother? Active phase of labor Latent phase of labor Transition phase of labor Final phase of labor
Transition phase of labor
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Turn her or ask her to turn to her side. Help the woman to sit up in a semi-Fowler's position. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.
Turn her or ask her to turn to her side.
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: baseline variability. baseline FHR. fetal bradycardia. short-term variability.
baseline FHR.
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 5 minutes every 10 minutes every 20 minutes every 15 minutes
every 15 minutes
A nursing student correctly identifies that an episiotomy that extends straight down into the true perineum is which of the following? mediolateral episiotomy lateral episiotomy midline episiotomy unilateral episiotomy
midline episiotomy
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? accelerations variable decelerations early decelerations prolonged decelerations
prolonged decelerations
The injection of a local anesthetic to block specific nerve pathways is referred to as: gas administration. pudendal block. amnesic medication. natural anesthesia.
pudendal block
A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement? "Continuous labor support can result in better labor outcomes." "Anxiety can slow down the labor process." "Anxiety can speed up the labor process." "Nurses can influence birth outcomes in a positive way."
"Anxiety can speed up the labor process."
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? "I have never read or heard of this happening." "The injection is given in the space outside the spinal cord." "An injury is unlikely because of expert professional care given." "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."
"The injection is given in the space outside the spinal cord."
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? +4 0 -2 +2
-2
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: 7.21. 7.20. 7.15 or less. 7.25 or more.
7.15 or less.
Mrs. Atkins is 40 weeks' pregnant by ultrasound, and the induction of labor is being discussed by Mrs. Atkins and her birth attendant. The birth attendant tells Mrs. Atkins, "I am going to do a pelvic exam so that I can assess your readiness for labor. I will obtain what is known as a Bishop score, and it will tell me how ready you are to go into labor." What Bishop score would indicate a favorable response to oxytocin-induced labor? 6 or above 5 or below 8 or above 3 or below
8 or above
A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? Agree with the client, and administer the drug immediately to keep the pain manageable. Explain to the client that opioids should only be administered an hour or less before birth. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Refuse to administer opioids because they can develop dependency in the client and the fetus.
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? Uterus Perineum False pelvis Cervix
Cervix
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? Advocate for the client to have a vaginal examination. Promptly inform the primary care provider. Reposition the client. Continue to monitor the client and the fetal heart rate..
Continue to monitor the client and the fetal heart rate..
Which nursing action is applied throughout all stages of labor? Limit the client to have no more than one support person in the labor room. Place the client on nothing by mouth (NPO) status while in labor. Do not allow the client to lay flat on her back for long periods. Discourage the client from ambulating after the rupture of membranes.
Do not allow the client to lay flat on her back for long periods.
The type of skin incision done for a cesarean birth will indicate the type of uterine incision. True False
False
Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner? Instruct the client to bare down and push with each contraction. Instruct the client to change positions frequently. Instruct the client to limit fluid intake until after the second stage of labor. Instruct the client to blow through the lips like blowing out candles.
Instruct the client to blow through the lips like blowing out candles.
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 temperature increases from 99° F (37.2° C) to 100° F (37.8° C). Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Maternal respirations decrease from 20 to 14 breaths/minute. Maternal pulse increases from 78 to 96 beats/minute.
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.
General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? The client is more sensitive to preanesthetic medications. The client is less sensitive to inhalation anesthetics. Fetal hypersensitivity to anesthetic is possible. Neonatal depression is possible.
Neonatal depression is possible.
A 24-year-old primigravida has been laboring longer than 24 hours. She has entered the second stage of labor, and the baby is at +2 station. The fetal heart rate has been 90 bpm for the last 2 minutes. The physician applies a Kiwi vacuum; after 3 attempts (pop-offs), the baby is not delivered, and the fetal heart rate is still 90 bpm. What should the nurse do next? Choose the best answer. Prepare an amnioinfusion. Prepare for a forceps birth. Hand the physician a Malmstrom vacuum and prepare for another round of 3 attempts. Prepare for an emergency cesarean birth.
Prepare for an emergency cesarean birth.
A laboring client is restless and moving frequently in the bed. She appears to be more uncomfortable with the contractions but refuses pain medication when offered. The client's partner has left the room to stretch his legs. Which response by the nurse is most helpful? Turn on the television as a focal point. Stand silently at the back of the room. Stand next to the client at the side of the bed. Turn up the volume of music playing in the room.
Stand next to the client at the side of the bed.
A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important in affecting the birth process? Select all that apply. Occipitofrontal Occipitomental Suboccipitobregmatic Biparietal Diagonal conjugate
Suboccipitobregmatic Biparietal
Which nursing action would the nurse anticipate doing more often for a cesarean birth newborn than a vaginal birth newborn? Suction the upper airway. Monitor the temperature. Note the number of stools. Assess voiding.
Suction the upper airway.
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? Notify the client's support person that the labor is typically long. Prepare for vital signs and fetal monitoring hourly. Take no extra measures; prepare for a standard labor. Anticipate this client is a one-to-one registered nursing assignment.
Take no extra measures; prepare for a standard labor.
The client may spend the latent phase of the first stage of labor at home unless which occurs? The client passes the bloody show The contractions vary in length and intensity The client begins back labor The client experiences a rupture of membranes
The client experiences a rupture of membranes
During labor, a pregnant client's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? The client is focusing on a painting during contractions. The client is not complaining of leg cramps. The client asks for a cold compress at the end of a contraction. The client is not requesting pain medication.
The client is not requesting pain medication.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client has contractions once every two minutes. The client experiences her first full contraction. The client's cervix is fully dilated. The infant is born.
The client's cervix is fully dilated.
The pain of labor is influenced by many factors. What is one of these factors? The woman has a high threshold for pain. The woman is prepared for labor and birth. The woman has a high tolerance for pain. The woman has lots of visitors during labor.
The woman is prepared for labor and birth.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? Fourth First Second Third
Third
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? This would cause fetal depression in utero. This can lead to maternal hypertension. This may prolong labor and increase complications. The effects would wear off before birth.
This may prolong labor and increase complications.
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Leopold maneuver Nonstress test Urinalysis Vaginal examination
Vaginal examination
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Women report higher levels of satisfaction when regional anesthetics are used to control pain. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? greenish fluid noted on the client's underwear a positive bacterial culture a positive nitrazine test leakage from the perineum when the client coughs
a positive nitrazine test
The nurse is caring for a client recovering from a cesarean birth. Which assessment should the nurse make a priority for this client? breast filling plan to breastfeed abdominal texture perineum for edema
abdominal texture
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? encouraging the woman to use relaxation techniques providing clear information about procedures promoting the woman's feelings of control allowing the woman time to be alone
allowing the woman time to be alone
Which action is a priority when caring for a woman during the fourth stage of labor? offering fluids as indicated encouraging the woman to void assisting with perineal care assessing the uterine fundus
assessing the uterine fundus
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? regular contractions cervical dilation (dilatation) fetal movement through the birth canal placental separation
cervical dilation (dilatation)
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? intact membranes floating presenting fetal part cervical dilation (dilatation) of 2 cm or more a neonatologist to insert the electrode
cervical dilation (dilatation) of 2 cm or more
A woman is being seen in the clinic for care during her first pregnancy and birth. The nurse will educate this woman and her significant other about their planned cesarean birth and what can be expected. When should the nurse provide this family education? each time the nurse sees the woman before surgery only when she and her significant other can come to the clinic together when the client presents for admission for the procedure at a preset time one month prior to the scheduled delivery
each time the nurse sees the woman before surgery
A nursing student correctly identifies which of the following as the most important predictor of fetal maturity? cervical readiness date that fetal heart tones were first heard fetal lung maturity pregnancy dated as completing at least 38 weeks' gestation
fetal lung maturity
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? footling frank complete full
frank
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? passage of the drug to the fetus excessive contractions of the uterus increased frequency of micturition headache following anesthesia
headache following anesthesia
A nurse correctly recognizes which of the following as a current trend within the population of birthing women? more natural births with fewer medical interventions decreased use of epidurals increased rates of cesarean sections increased public funds for using doulas
increased use of epidurals
A young woman comes into the clinic in the eighth month of her pregnancy. She is requesting information regarding cesarean delivery and wants to discuss this method of birth. The nurse knows that the rate of cesarean deliveries has increased because of which reasons? Select all that apply. rise in the number of older pregnant women increased incidence of maternal obesity increased use of induction for nonmedical reasons an increase in vaginal birth after cesarean (VBAC) attempts change in perception of risk by clients and physicians
increased use of induction for nonmedical reasons rise in the number of older pregnant women change in perception of risk by clients and physicians increased incidence of maternal obesity
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: active phase of the first stage. pelvic phase of the second stage. latent phase of the first stage. early phase of the third stage.
latent phase of the first stage.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? presentation lie attitude position
lie
To prevent tearing of the perineum of a client during birth, a physician performs a mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral episiotomy over a midline episiotomy is which of the following? less postpartal discomfort less blood loss easier healing lower rlsk for rectal mucosal tear
lower rlsk for rectal mucosal tear
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal bradycardia maternal hypertension and fetal tachycardia maternal hypotension and fetal tachycardia maternal hypertension and fetal bradycardia
maternal hypotension and fetal bradycardia
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? thiopental meperidine secobarbital hydroxyzine hydrochloride
meperidine
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds contractions noted in the front of abdomen that stop when she walks moderately strong contractions every 4 minutes, lasting about 1 minute increased energy level with alternating strong and weak contractions
moderately strong contractions every 4 minutes, lasting about 1 minute
After pelvic measurements, a client who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this? passenger powers psychological outlook passageway
passageway
The physician has just examined the patient and determined that she requires a cesarean birth. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision: reduces the risk of uterine rupture. is larger than a classical incision and will allow for easier delivery. has a lower risk of maternal injury. is less complicated to perform.
reduces the risk of uterine rupture.
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? hyperreflexia abdominal distention urinary retention respiratory depression
respiratory depression
While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? bradycardia and auscultation of fluid in the base of the lungs bradypnea and hypertension tachycardia and a falling blood pressure tachypnea and a widening pulse pressure
tachycardia and a falling blood pressure
Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to: administer oxygen by facemask. ask her to inhale deeply at least five times. turn her on her left side or raise her legs. raise her head off the bed.
turn her on her left side or raise her legs.
While the nurse is assessing the prenatal client's understanding of the information provided at a recent appointment, the client states, "I want to avoid the pain and long hours of labor, so I'm electing to have a cesarean birth." How should the nurse respond? "A cesarean birth is a method to be used when vaginal birth is not possible—it is not a true option." "Cesarean birth is a low-risk surgery that is the ideal option in many cases." "It is important to inform the health care provider of your decision so that we can plan appropriately for when the birth occurs." "Many women elect to have a cesarean birth to avoid the risk of anoxia."
"A cesarean birth is a method to be used when vaginal birth is not possible—it is not a true option."
A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. What would be the nurse's best response? "You will like cesarean birth so much that you will want repeat cesarean births in the future." "Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth." "There is no way to predict that; it will depend on your individual uterine anatomy." "Yes. 'Once a cesarean always a cesarean' is a well-known rule."
"Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth."
How should the nurse counsel a client who has arrived for a scheduled repeat cesarean birth? "An IV catheter will be placed, and we will do some preoperative blood work. Then we will give you some antibiotics." "After surgery, you will be immediately transferred to the postpartum unit." "A Foley catheter will be inserted before surgery and will be removed once you arrive to the postpartum unit." "You will undergo general anesthesia, so you will be asleep during the procedure."
"An IV catheter will be placed, and we will do some preoperative blood work. Then we will give you some antibiotics."
A woman who underwent a primary cesarean birth for a breech presentation states that her neonate seems to have so much more mucus than her first baby. Concerned, she asks why this has happened. How should the nurse respond? "Babies born by cesarean section have more respiratory complications because they do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal." "All babies are different so it is unwise to make comparisons." "There is no scientific reason for this occurrence." "The pain medication given during the surgery may have contributed to the mucus build up."
"Babies born by cesarean section have more respiratory complications because they do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal."
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 causes the release of endorphins." "It blocks the transmission of nerve messages of pain at the receptors." "It distracts your brain from the sensations of pain." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."
"It distracts your brain from the sensations of pain."
A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is elongated, the width is roomy, but the length is narrow." "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through."
"It is rounded in shape and allows ample room for the neonate to fit through the passageway."
A client who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births? "All future births must be done through cesarean." "Most women prefer cesarean births because they are quicker and cause less pain." "Your health care provider will let you know what kind of birth you can have." "Not if you fulfill the criteria for vaginal birth after cesarean."
"Not if you fulfill the criteria for vaginal birth after cesarean."
When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies? "Who do you want to be with you when you are in labor?" "How do you want the health care team to plan your care?" "Tell me how you handled labor pain in your past deliveries." "Picking from these options, what options do you feel is best?"
"Tell me how you handled labor pain in your past deliveries."
An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? "The client is experiencing lower back pain and I gave a backrub." "I instructed the client to ring if she felt the need to move her bowels." "The client reports a pain level of 8. She has a low pain tolerance." "I changed the client position from her back to her side."
"The client reports a pain level of 8. She has a low pain tolerance."
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? "The temperature of the water should be at least 105℉ (40.5℃)." "The warmth and buoyancy of the water has a nice relaxing effect." "My cervix should be dilated more than 5 cm before I try using this method." "I can stay in the bath for as long as I feel comfortable."
"The temperature of the water should be at least 105℉ (40.5℃)."
A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? Tell her that it is her decision, but that she will be placing herself and her baby at grave risk. A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. Explain that you will have to call the physician and get an order to leave the fetal monitor off.
A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Elevate her hips to prevent cord prolapse. Assess fetal heart rate for fetal safety. Test a sample of amniotic fluid for protein. Ask her to bear down with the next contraction.
Assess fetal heart rate for fetal safety.
During which time is the nurse correct to document the end of the third stage of labor? When the mother is moved to the postpartum unit Following fetal birth At the time of placental delivery When pushing begins
At the time of placental delivery
During which time is the nurse correct to document the end of the third stage of labor? When the mother is moved to the postpartum unit When pushing begins At the time of placental delivery Following fetal birth
At the time of placental delivery
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor? Pain originates from the cervix and lower uterine segment. Diffuse abdominal pain signals a complication with progression of labor. It is reported as the worst pain a woman will ever feel. Pain is focal in nature.
Pain originates from the cervix and lower uterine segment.
A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"? Do a sterile "in and out" catheterization every 3 hours Insist the client use a bedpan every 2 hours Limit fluid intake to 300 mL every hour Palpate the area above the symphysis pubis every 2 hours.
Palpate the area above the symphysis pubis every 2 hours.
The maternal health nurse is caring for a group of pregnant clients. Which client will the nurse determine is most ready for labor? The client who is 41 weeks gestation today. The client whose cervical length via endovaginal ultrasound has increased. The client whose cervical secretions are negative for fetal fibronectin. The client whose Bishop score is 9 today.
The client whose Bishop score is 9 today.
Which client outcome during active and transitional labor is best? The client will tolerate 8 oz (240 ml) of clear liquids during labor process. The client will walk in the hall for 15 minutes every 2 hours. The client will state a pain level of 7 and under during contractions. The client will practice breathing techniques during contractions.
The client will practice breathing techniques during contractions.
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? The infant may show increased drowsiness. The mother may have difficulty working effectively with contractions. The father's coaching role may be disrupted at times. The mother may have continued memory loss postpartum
The mother may have difficulty working effectively with contractions.
Which nursing action has a negative effect on fetal descent? administering opioid pain medication using a tap water enema walking the client in the hall laying the client on the left side
administering opioid pain medication
A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? administration of 1000 mL of IV glucose solution move the woman into a supine position administration of aspirin administration of 500 mL of IV Ringer's lactate
administration of 500 mL of IV Ringer's lactate
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: effleurage. acupressure. therapeutic touch. patterned breathing.
effleurage
Which intervention would be least effective in caring for a woman who is in the transition phase of labor? providing one-to-one support having the client breathe with contractions urging her to focus on one contraction at a time encouraging the woman to ambulate
encouraging the woman to ambulate
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? alleviating perineal discomfort with the application of ice packs palpating the woman's fundus for position and firmness completing the identification process of the newborn with the mother encouraging the woman to push when she has a strong desire to do so
encouraging the woman to push when she has a strong desire to do so
The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor? every 10 to 15 minutes every 2 to 4 hours every 15 to 30 minutes every 45 to 60 minutes
every 15 to 30 minutes
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? variable decelerations, too unpredictable to count fetal baseline rate increasing at least 5 mm Hg with contractions a shallow deceleration occurring with the beginning of contractions fetal heart rate declining late with contractions and remaining depressed
fetal heart rate declining late with contractions and remaining depressed
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 beats/min The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. uteroplacental insufficiency fetal movement opioid medication to maternal client maternal fever fetal distress
fetal movement fetal distress uteroplacental insufficiency maternal fever
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication? naloxone epinephrine ampicillin indomethacin
naloxone
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? accidental intrathecal block postdural puncture (spinal) headache respiratory depression a failed block
respiratory depression
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? uterus becoming discoid shaped sudden gush of dark blood from the vagina shortening of the umbilical cord boggy, soft uterus
sudden gush of dark blood from the vagina
