Chapter 13: Nursing Care During Labor and Birth

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.)

- Dry the infant off with sterile towels. - Place stockinette cap on infant's head. - Remove wet linen as needed

A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)

- Less maternal fatigue - Less birth canal injuries - Decreased pushing time

The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

- Maternal hypotension - Meconium-stained amniotic fluid - Maternal fever—38° C (100.4° F) or higher

When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)

- Monitor and record vital signs frequently during the course of labor - Document the FHR pattern, noting baseline and response to contraction patterns. - Indicate on the EFM tracing when maternal position changes are done.

Which interventions are required following an amniotomy procedure? (Select all that apply.)

- Notation related to amount of fluid expelled - Color and consistency of fluid - Fetal heart rate

The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

- Soft boggy uterus - High uterine fundus displaced to the right - Intense vaginal pain unrelieved by analgesics

The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places.

0.75

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

18-gauge

At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?

8

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. The Apgar score for this infant is:

9

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?

Anxiety related to imminent birth process

The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action?

Encourage the patient to exhale in short breaths with contractions.

The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse's priority action with this procedure?

Assess the fetal heart rate immediately after the procedure.

A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?

Auscultate anterior and posterior breath sounds.

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

Clear with bits of vernix caseosa

Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?

Client has received an epidural for pain control during the labor process.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be:

Discharged home to await the onset of true labor.

The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

Document this evidence of normal early maternal-infant attachment behavior.

Which assessment finding could indicate hemorrhage in the postpartum patient?

Elevated pulse rate

A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?

Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

Every 30 minutes

The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record?

Fetal heart rate

A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:

Fetal heart rate, maternal vital signs, and the woman's nearness to birth.

Which client at term should go to the hospital or birth center the soonest after labor begins?

Gravida 3, para 2, whose longest previous labor was 4 hours

Which is an essential part of nursing care for a laboring client?

Helping the woman manage the pain

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?

Inform the mother that the rate is normal.

Which should the nurse recognize as being associated with fetal compromise?

Meconium-stained amniotic fluid

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?

Place a small pillow under the patient's left hip.

Which comfort measure should a nurse use to assist a laboring woman to relax?

Recommend frequent position changes.

The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure?

Recording the character and amount of amniotic fluid

The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head?

Restitution

Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth?

The vulva bulges and encircles the fetal head.

The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?

To determine cervical dilation and effacement

The nurse is preparing to perform Leopold's maneuvers. Why are Leopold's maneuvers used by practitioners?

To determine the best location to assess the fetal heart rate

A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

a trickle of fluid from the vagina.

A nursing priority during admission of a laboring client who has not had prenatal care is:

identifying labor risk factors.

During labor a vaginal examination should be performed only when necessary because of the risk of:

infection.

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to:

massage the fundus.

When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the):

both sides of the maternal abdomen

The nurse is performing Leopold's maneuvers on a client. Which figure depicts the Leopold's maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis. Refer to Figures a to d.

c.

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely

common during the transition phase of labor.

The nurse has given the newborn an Apgar score of 5. She should then:

gently stimulate by rubbing the infant's back while administering O2.

The nurse thoroughly dries the infant immediately after birth primarily to:

reduce heat loss from evaporation