CH 14.

A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Time the contractions. Auscultate the fetal heart tones. Contact the primary care provider. Inspect the perineum.

Inspect the perineum. Explanation: The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.

A client has just received combined spinal epidural. Which nursing assessment should be performed first? Assess vital signs. Assess pain level using a pain scale. Assess for progress in labor. Assess for spontaneous rupture of membranes. Assess for fetal tachycardia.

Assess vital signs. Explanation: The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

The pain of labor is influenced by many factors. What is one of these factors? The woman is prepared for labor and birth. The woman has a high tolerance for pain. The woman has a high threshold for pain. The woman has lots of visitors during labor.

The woman is prepared for labor and birth. Explanation: The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

As a woman enters the second stage of labor, which would the nurse expect to assess? feelings of being frightened by the change in contractions reports of feeling hungry and unsatisfied falling asleep from exhaustion expressions of satisfaction with her labor progress

feelings of being frightened by the change in contractions Explanation: The nature of contractions changes so drastically— the urge to push is very strong—that this can be frightening.

The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize? Assess return of sensory and motor functions to the lower extremities. Help the client get up and walk around immediately. Let the client rest and recover while keeping her legs slightly elevated. Make sure the client receives plenty of fluids.

Assess return of sensory and motor functions to the lower extremities. Explanation: After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time (at least until the medication wears off). Do not elevate the legs; the goal is to maintain normal circulation. Fluids are important, but they are not related to the epidural or to the metabolism of the medication.

A client arrives at the clinic in labor. The nurse assesses a bulging perineum and prepares for the birth. Place the nurse's actions in sequence. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Call for assistance 2 Put on gloves 3 Support perineum with one hand 4 Deliver the head 5 Palpate for a nuchal cord 6 Use bulb to suction mouth and nose

Call for assistance Put on gloves Support perineum with one hand Deliver the head Palpate for a nuchal cord Use bulb to suction mouth and nose Explanation: The nurse assesses a bulging perineum noting that birth is imminent. The nurse would call for assistance, put on gloves, support the perineum, deliver the head, palpate for a nuchal cord, and use bulb to suction mouth and nose.

The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize? Check the chart for the last void. Notify the health care provider about the mass. Ask the client if the mass has always been present. Assume this is part of the uterus.

Check the chart for the last void. Explanation: The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be handled by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? Check the pH to ensure the fluid is amniotic fluid. Prepare to administer an antibiotic. Notify the health care provider about possible meconium. Check the maternal heart rate.

Notify the health care provider about possible meconium. Explanation: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? application of vibroacoustic stimulation tactile stimulation administration of oxygen by mask fetal scalp stimulation

administration of oxygen by mask Explanation: The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.

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? "An injury is unlikely because of expert professional care given." "I have never read or heard of this happening." "The injection is given in the space outside the spinal cord." "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

ect response: "The injection is given in the space outside the spinal cord." Explanation: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

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 thiopental hydroxyzine hydrochloride secobarbital

meperidine Explanation: Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the opioid or reduce anxiety.

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat? "You could have some hard candy to suck on." "What would you like to eat?" "You can have a protein supplement." "I can get you something soft and easy to digest, like pudding."

"You could have some hard candy to suck on." Explanation: The woman can be encouraged to sip fluid, ice chips, or suck on hard candy if she becomes thirsty or nauseated by labor. It also helps to supply extra fluid. Although many hospital protocols dictate that women who present in labor should not partake of oral nutrition, there is little evidence to support this restrictive practice. However, if women are kept NPO during labor, they can be administered anesthesia safely in an emergency.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? having the client breathe with contractions providing one-to-one support encouraging the woman to ambulate urging her to focus on one contraction at a time

encouraging the woman to ambulate Explanation: Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.