Childbearing Practice Unit 4
A nurse is caring for a woman at term in active labor. A vaginal exam reveals the cervix to be 4 cm, 60%, -1 station. What question would the nurse expect the woman to ask?
"When can I get my epidural?"
The rubella vaccine has been prescribed for a new mother. Which of the following statements should the postpartum nurse make when providing information about the vaccine to the client?
"You should not become pregnant for 1 to 3 months after the administration of the vaccine."
The nurse is teaching a new mother about prevention of mastitis. The nurse correctly teaches which of the following as being protective for development of mastitis?
Emptying at least one breast with each feeding reduces stasis and inflammation in the breast.
Th nurse is calling a patient for a follow up on day four postpartum. The patient expresses concern about lochia flow stating that the lochia has become pink with brown red streaks and some bits of "sludge" are in the lochia. What is the nurse's best response to this patient?
Explain to the mother on day four postpartum lochia changes to serosa. This is normal.
An obese patient delivered a 10 lb. 14 oz. infant by caesarean section four days ago. The nurse performs a postpartum assessment and finds which of the following signs of a superficial thrombophlebitis?
Hot tender lump in posterior leg with erythema
The nurse in the outpatient clinic is planning care for a 34-year-old gravida I, para 1 client who has onychomycosis and is receiving topical antifungal medication. Which of the following interventions should the nurse include in the client's plan of care?
Investigate whether the client is breastfeeding their child.
A nurse assists with artificial rupture of membranes for a patient. Upon rupture copious clear fluid is noted. Fetal heart rate is 130-140 range 126-152. Thirty minutes later the fetal heart rate is essentially the same but with deep sudden decelerations to 70-90 are noted. The nurse is aware that the probable cause of these decelerations is which of the following?
Loss of cord cushion
The nurse is caring for a patient who delivered a 9 lb. 2 oz. infant. 45 minutes ago. The assessment reveals the fundus boggy, two fingers above the umbilicus, and deviated to the right. Bleeding is heavy rubra. What is the nurse's first action?
Massage the fundus to make the uterus firm.
The nurse is caring for a patient in active labor with a request for epidural anesthesia. The nurse is aware of increased risk for which of the following complications with placement of an epidural for anesthesia?
Maternal dizziness and nausea from hypotension
The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:
Placental separation
A nurse caring for a patient postpartum notes unusual behaviors and emotional liability with the inability to understand care for her own personal hygiene. Which of the following does the nurse suspect for this mother?
Postpartum psychosis
A nurse admits a laboring woman to the triage area. A vaginal exam reveals a breech presentation of the fetus. The nurse should take which of the following actions?
Prepare for a caesarean section.
The nurse caring for a woman in active labor notes late decelerations in the fetal heart tones. The first action of the nurse would be to:
Reposition the woman.
Care during this phase of labor includes: Maternal and FHR assessment 15-30 minutes Massage, shower, birthing ball Ice chips Epidural
Stage 1 - Active Phase
Identify the stage/phase of labor Contractions: Moderate to Strong 3-5 minutes apart 40-70 Seconds Dilation 4-7 cm
Stage 1 - Active Phase
Care during this phase of labor includes: Maternal and FHR assessment 30-60 minutes Encourage the mother to walk, rock Sip fluids, rest or light activity, light nutrition
Stage 1 - Latent Phase
Identify the stage/phase of labor Contractions: Mild to Moderate 5-20 minutes apart 30-45 Seconds Dilation 0-3 cm
Stage 1 - Latent Phase
Identify the stage/phase of labor Contractions: Strong to Very Strong 2-3 minutes - minimal breaks 45-90 Seconds Dilation 8/10 cm May not be recognized in patients with epidurals. No longer considered a separate phase from Active.
Stage 1 - Transition Phase
Care during this phase of labor includes: Assist with bearing down into perineum stretch perineum back from fetal head bring legs back with pushes
Stage 2 - Active Phase
Care during this phase of labor includes: Assist with bonding Observe for a gush of fluid & lengthening of cord
Stage 3
Identify the stage/phase of labor Last 5 - 20 minutes Ends with the delivery of the placenta
Stage 3
Care during this phase of labor includes: Start breastfeeding if indicated Monitor vital signs Monitor fundal status Monitor bleeding Assist with bonding
Stage 4
A nurse assesses a patient entering recovery after delivering an 8 lb. 2 oz. infant with polyhydraminos. The patient was given an epidural in labor. The patient's fundus is firm and noted up 3 fingers over the umbilicus and deviated to the left. Bleeding is noted as scant to moderate rubra. What is the first action of the nurse in caring for this patient?
Straight catheterize the bladder to empty.
The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse assesses that the amniotic fluid is normal if it has which of the following characteristics?
Straw-colored, with flecks of vernix
The home nurse evaluates a patient who vaginally delivered a term infant after 36 hours with ruptured membranes. The patient complains of an increasingly tender fundus and foul odor to moderate lochia serosa. What further assessment would this nurse check immediately?
Temperature greater than 100.4 f.
The nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following is documented in the client's record?
The cervix is completely dilated.
The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The initial nursing action is to:
Determine the fetal heart rate.
A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which of the following findings indicates that the rate of the infusion needs to be decreased?
A fetal heart rate of 180 beats/min
A woman G 2 T 1 P 0 A 0 L 1 is admitted to labor and delivery in early active labor. The decision is made to rupture membranes to speed labor. The nurse would expect which of the following effects of an amniotomy?
A moderate amount of clear fluid.
The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which most appropriate nursing actions?
Administering oxygen via face mask
A nurse has just received the intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which of the following clients is most at risk for developing postdelivery endometritis?
An adolescent experiencing an emergency cesarean delivery for fetal distress
The nurse receives a call on the unit's warm line from a mother who delivered a week ago. The mother is tearful and states she is terrified that harm will come to the baby. She further states that she is hearing voices telling her to harm her baby. The nurse understands the most appropriate intervention for this patient is which of the following?
Arrange for immediate inpatient psychiatric care.
A patient is 38 hours postpartum after vaginal delivery with uterine inversion at delivery. The nurse is assessing the patient while preparing her for discharge. The mother complains of increasing fundal tenderness. What is the nurse's best next action?
Assess the patient's temperature and lochia for odor.
A newly delivered multipara mother breastfeeds her infant and complains of uterine cramping. The nurse understands the reason for this uterine cramping is:
the natural pitocin that causes milk ejection contracts the uterus.
A primipara mother is exploring her new infant placed on her abdomen. The nurse notes the mother first:
touches the infant with her fingertips then whole hand.
