exam 2 Questions

Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following​ occur?

1)Rupture of membranes​ (ROM) 2)Decreased fetal movement 3) Any vaginal bleeding ​Regular, frequent uterine contractions​ (UCs)

The clinical coordinator is observing a nursing student as he provides care to a patient who is in early labor. Which of the student's actions should be addressed for correction during the student's daily clinical evaluation? A. Application of a fetal heart monitor followed by an explanation of the reason for its use B. Upon entering the patient's room, speaking with the patient prior to looking at the fetal heart monitor C. Using layman's terms to provide the patient with an explanation of the rationale for electronic fetal monitoring D. Incorporating cues that arise from intuition or from observations of the patient and family as opposed to focusing on the fetal heart monitor

A. Application of a fetal heart monitor followed by an explanation of the reason for its use Before using the electronic fetal monitor, the nurse needs to fully explain to the patient the reason for its use and the information that it can provide. The nurse can acknowledge the patient's need to be the central focus by always speaking to and looking at the woman when entering the room, before looking at the monitor. The technical language of electronic fetal monitoring and other procedures may act as a barrier, isolating the patient and emphasizing her experience. To prevent dehumanization of the nurse-patient relationship, the nurse should incorporate cues that may arise from intuition or from observations of or interactions with the patient and family, as opposed to focusing only upon objective monitor-based data.

The nurse is teaching a prenatal class about false labor. The nurse should teach patients that false labor most likely will include which of the following? (Select all that apply.) A. Contractions that do not intensify while walking B. An increase in the intensity and frequency of contractions C. Progressive cervical effacement and dilatation D. Pain in the abdomen that does not radiate E. Increased thin vaginal secretions

A. Contractions that do not intensify while walking D. Pain in the abdomen that does not radiate True labor contractions intensify while walking. True labor results in pain beginning low in the abdomen and radiating upward or into the back. True labor results in increased intensity and frequency of contractions. True labor results in progressive dilation. True labor results in an increase in vaginal secretions.

A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are two minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure. How should the nurse interpret this complaint? A. The patient's complaint is congruent with her current stage of labor B. The patient's complaint may indicate the need for delivery via cesarean section C. Based upon the patient's complaint, she is experiencing the active phase of labor D. The patient's complaint is consistent with placental separation, which is normal for her current stage of labor

A. The patient's complaint is congruent with her current stage of labor The objective findings and patient's complaint are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). The objective findings and patient's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). Placental separation occurs after the infant is born.

A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately: A. Change the patient's position in bed B. Notify the physician that birth is imminent C. Administer oxygen at 2 liters per minute D. Begin continuous fetal heart rate monitoring

D. Begin continuous fetal heart rate monitoring. Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the patient's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any​ abnormalities, how often would the nurse expect to take the​ client's temperature?

Q4 hours

desired v/s for baby?

RR-30-60 irregular AP-110-160 Temp: skin above 97.8 skin color:pink with bluish extremities gestational age: 38-42 weeks sole creases on the heel

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily​ done?

To contract the uterus and minimize bleeding

Thirty minutes after birth, the nurse assesses a woman's fundus as soft and boggy. What action by the nurse takes priority? a. Take the blood pressure. b. Massage the fundus. c. Notify the provider or nurse-midwife. d. Place the woman in the Trendelenburg position.

b. Massage the fundus.

To assess the duration of labor contractions, the nurse determines the time a. from the beginning of one contraction to the beginning of the next. b. from the beginning to the end of each contraction. c. of the strongest intensity of each contraction. d. of uterine relaxation between two contractions.

b. from the beginning to the end of each contraction.

A student asks how pregnant women can usually tolerate the normal blood loss associated with childbirth. Which response by the nurse is best? "It is because they have a. a higher hematocrit." b. increased blood volume." c. a lower fibrinogen level." d. increased leukocytes."

b. increased blood volume."

The labor and delivery nurse is evaluating a newly admitted woman's lab and notes a hemoglobin of 9.1 mg/dL and hematocrit of 31%. What action by the nurse takes priority? a. Document the findings on the woman's chart. b. Notify the provider or nurse-midwife immediately. c. Assess for response to blood loss during and after birth. d. Place the patient on bedrest during labor.

c. Assess for response to blood loss during and after birth.

The nurse thoroughly dries the infant immediately after birth primarily to a. stimulate crying and lung expansion. b. remove maternal blood from the skin surface. c. reduce heat loss from evaporation. d. increase blood supply to the hands and feet.

c. reduce heat loss from evaporation.

The nurse is caring for a patient in the transitional stage of labor. What objective data would indicate that the patient is having pain? a. Dilated pupils and increased blood pressure b. Muscle tension and decreased blood pressure c. Decreased respiration and increased blood pressure d. Increased pulse and decreased blood pressure

Answer: a. Dilated pupils and increased blood pressure Feedback: Dilated pupils, along with increased blood pressure, pulse, and respiration rate, indicate pain. Muscles would be tense.

A laboring patient in the birthing center has a hematocrit of 49. The nurse should anticipate that this finding is related to: a. Anemia. b. Dehydration. c. Hemorrhage. d. Infection.

Answer: b. Dehydration. Feedback: Dehydration is indicated by a hematocrit of 49% resulting from hemoconcentration. Anemia and hemorrhage are indicated by low hemoglobin. Infection is indicated by a high white blood cell count.

A G1P0 patient calls the hospital and asks the nurse, "I think I am having labor pains. When should I come to the hospital?" The nurse correctly replies that the patient should come in when her contractions are: a. Three minutes apart for 30 minutes. b. Five minutes apart for one hour. c. Five to 10 minutes apart for 30 minutes. d. Ten to 15 minutes apart for one hour.

Answer: b. Five minutes apart for one hour. Feedback: The nullipara patient should come in when her contractions are five minutes apart for one hour. The multigravida patient should come when contractions are three minutes apart for 30 minutes.

The nurse is caring for four patients in the birthing center. Which patient should the nurse encourage to ambulate? a. G2P1 with ruptured membranes and 0 engagement b. G3P2 with intact membranes and 4 cm dilation c. G4P3 with ruptured membranes and 9 cm dilation d. G5P4 with intact membranes and 8 cm dilation

Answer: b. G3P2 with intact membranes and 4 cm dilation Feedback: The patient that is G3P2 with intact membranes and 4 cm dilation should be encouraged to ambulate. If membranes are ruptured and the presenting part is not engaged, there is risk of prolapsed cord. A multigravida at 8 or 9 cm should labor in bed or a chair.

The nurse is caring for four laboring patients at Stage 1 of labor. Which patient is demonstrating responses commonly seen during the latent phase? a. A patient with increased fatigue, restlessness, and anxiety b. A patient with increased irritability and feeling out of control c. A patient who is happy and talkative d. A patient who has just delivered a healthy newborn

Answer: c. A patient who is happy and talkative Feedback: A patient who is happy and talkative is demonstrating responses commonly seen during the latent phase. Increased fatigue, restlessness, and anxiety are commonly seen during the active phase. Increased irritability and feeling out of control are responses commonly seen during transition. Birth occurs at the end of the second stage of labor.

A Hmong patient has just given birth to a 5-pound baby girl. What culturally sensitive nursing action is appropriate at this time? a. Comment on the daintiness of her baby girl. b. Encourage the patient to eat cold foods and drink cold fluids. c. Offer the mother a soft-boiled egg to eat. d. Assist the mother in bathing the baby.

Answer: c. Offer the mother a soft-boiled egg to eat. Feedback: Offering the mother a soft-boiled egg to eat is the culturally sensitive nursing action appropriate for the postpartum Hmong patient. Commenting on the daintiness of her baby girl and assisting the mother in bathing the baby is not a cultural preference. Warm foods are preferred by this culture at this time, so offering cold foods would not be appropriate.

A low-risk patient's vaginal exam reveals that her cervix is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this patient's vital signs? a. Every five minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes

Answer: d. Every 30 minutes Feedback: The patient is in the transition phase of the first stage of labor. The nurse should assess vital signs every 30 minutes. More frequent assessment of vital signs is appropriate during the second and third stages and following anesthesia.

maternal v/s should be?

BP below 140/90 HR 60-100 temp 97-99 membranes ruptured and clear, no odor

The charge nurse is looking at the charts of laboring patients. Which patient most requires further intervention? 1. Multip at 7 cm, fetal heart tones auscultated every 90 minutes 2. Primip at 10 cm and pushing, external fetal monitor applied 3. Multip with meconium-stained fluid, internal fetal scalp electrode in use 4. Primip in preterm labor, external monitor in place

Correct Answer: 1 Rationale 1: During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is too infrequently. Rationale 2: External monitoring can be used instead of auscultation of the fetal heart tones during labor. Rationale 3: Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. Rationale 4: External monitoring during preterm labor will assess both contractions and fetal status.

The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the patient to change from Fowler's to left lateral position. 2. Apply oxygen to the patient at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid.

Correct Answer: 1 Rationale 1: The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the patient might get the fetus off the cord and eliminate the variable decelerations. Rationale 2: Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable. Rationale 3: There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations. Rationale 4: The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody.

The nurse is working with a pregnant adolescent. The patient asks the nurse how the baby's condition is determined during labor. Which statement indicates the patient education was successful? "During labor, the nurse will: 1. "Check your cervix by doing a pelvic exam every two hours." 2. "Assess the baby's heart rate with an electronic fetal monitor." 3. "Look at the color and amount of bloody show that you have." 4. "Verify that your contractions are strong but not too close together."

Correct Answer: 2 Rationale 1: Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. The patient has asked specifically about assessing fetal status in labor. Rationale 2: This option best answers the question the patient has asked. Rationale 3: Although bloody show is monitored, doing so does not assess fetal status. The patient has asked specifically about assessing fetal status in labor. Rationale 4: Although contraction strength is palpated abdominally, the patient has asked about assessing fetal status in labor.

The nurse is explaining to a student nurse how to determine fetal presentation and position by performing Leopold's maneuver. The nurse should explain that the second maneuver in this procedure is used to determine: 1. Whether the fetal head or buttocks occupies the uterine fundus. 2. The location of the fetal back. 3. Whether the pelvic inlet contains the head or buttocks. 4. The descent of the presenting part into the pelvis.

Correct Answer: 2 Rationale 1: The first maneuver determines what part of the fetus is in the fundus. Rationale 2: The second Leopold's maneuver determines the location of the fetal back. Rationale 3: The third maneuver determines which fetal part is in the pelvic inlet. Rationale 4: The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis.

Tearing happens in which phase?

Latent Phase

Two hours after​ delivery, a​ client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would​ take?

Massage the fundus until firm

the nurse should assess the placenta for?

2 arteries and 1 vein

What results from the adaptation of the fetus to the size and shape of the pelvis? a. Lightening b. Lie c. Molding d. Presentation

C. Molding

A​ client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse​ do?

Stay with the client and ask auxiliary personnel for assistance.

The labor and birth nurse is admitting a client. The​ nurse's assessment includes asking the client whom she would like to have present for the labor and​ birth, and what the client would prefer to wear. The​ client's partner asks the nurse the reason for these questions. What would the​ nurse's best response​ be?

"A client's preferences for her birth are important for me to​ understand." ​"Many women have beliefs about childbearing that affect these​ choices."

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are​ flexed, and resist straightening. What should the nurse record as this​ infant's Apgar​ score?

8

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the​ following?

1)Fetal heart rate of 130 with average variability 2)Blood pressure of​ 130/80 3) ​Odorless, clear fluid on underwear

At 1 minute after​ birth, the infant has a heart rate of 100 beats per​ minute, and is crying vigorously. The limbs are​ flexed, the trunk is​ pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this​ infant's Apgar​ score?

9

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.

A (Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.)

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. Dilation of the cervix. b. Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show.

A (The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor)

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void​ frequently?

A full bladder can impede fetal descent

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing​ attention?

A soaked perineal pad since the last​ 15-minute check

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? A) Biophysical profile (BPP). B) Ultrasound for fetal anomalies. C) Maternal serum alpha-fetoprotein (AF) screening. D) Percutaneous umbilical blood sampling (PUBS).

A) Biophysical profile (BPP). Rationale: BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies (B). Maternal serum AF screening is generally checked between 15 and 22 weeks to detect neural tube defects (C). Although PUBS is performed to determine a number of at-risk fetal conditions, the BPP determines current fetal risk (D).

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A) Come to the clinic today for an ultrasound. B) Go immediately to the emergency room. C) Lie on your left side for about one hour and see if the bleeding stops. D) Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A) Come to the clinic today for an ultrasound. Rationale: Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life-threatening to the mother and fetus--then (B) would be appropriate. (C) does not take the symptoms seriously. The woman is not describing symptoms of a UTI (D).

The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Prepare for imminent delivery. C) Apply oxygen via mask at 10 liters. D) Assist the client into the Fowler's position.

A) The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The fetal heart rate tracing is normal, no intervention is necessary. The client does not need to be assisted into the Fowler's position.

For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. A. The onset of progressive, regular contractions B. The bloody, or pink, show C. The spontaneous rupture of membranes D. Formulation of the woman's plan of care for labor E. Moderately painful contractions

A, B, C (Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Pain is subjective. The onset of progressive, regular contractions signals the beginning of labor, not the intensity of the pain.)

The nurse finds that the pregnant patient has impaired urinary elimination. Which interventions should be performed by the nurse to relieve the patient's problem? Select all that apply. A. Encourage the patient to urinate every 2 hours. B. Catheterize the patient immediately for voiding. C. Palpate patient's bladder superior to symphysis. D. Ask the patient to place the hand in running water. E. Provide effleurage massage to the patient frequently.

A, C, D (Impaired urinary elimination occurs as a result of sensory impairment caused by the labor process. Therefore the nurse has to perform interventions that help in emptying the patient's bladder every 2 hours. The nurse should encourage the patient to void every 2 hours to avoid bladder distention. The nurse can use running water to stimulate voiding by asking the patient to keep her hands in the running water. The nurse should palpate the patient's bladder on a frequent basis to detect the inability to void. The nurse should not catheterize the patient immediately for voiding, because it may result in trauma to the bladder. Effleurage helps in reducing pain but does not help stimulate voiding in the patient.)

Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. A. An admission to the hospital at the start of labor B. When accelerations of the fetal heart rate (FHR) are noted C. On maternal perception of perineal pressure or the urge to bear down D. When membranes rupture E. When bright, red bleeding is observed

A, C, D (Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM), a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.)

The nurse assesses a pregnant patient and reports to the primary health care provider (PHP) that the patient is in the second stage of labor. Which of the patient's signs enabled the nurse to give such a report to the PHP? Select all that apply. A. Urge to defecate B. Cheeks appear to be flushing C. Cervical dilation of 10 cm D. Brownish discharge of mucus from the vagina E. Premature urge to bear down

A, C, E (After an assessment, the nurse reports to the PHP that a pregnant patient is in the second stage of labor because the patient has a cervical dilation of 10 cm (fully dilated). The patient has a premature urge to bear down and an urge to defecate. The patient may have flushed cheeks in the active phase of first stage of labor, but it is not a sign of second stage of labor. Brownish discharge of mucus is a sign of latent phase of first stage of labor, but does not appear in the second stage of labor.)

A pregnant woman presents to the Emergency Department and reports that she has started labor and is certain the baby is coming "any minute now" and asks to be taken up to the delivery suite. The nurse assigned to provide care for this woman over a couple of hours determines that the woman is in "false" labor and is preparing her to return home. Which observation or observations support this conclusion? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.

A, C, E) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to the front, and the fact that activity does not increase contraction intensity.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) A) Reposition the client. B) Call the healthcare provider. C) Increase IV fluid. D) Provide oxygen via face mask.

A:1, B:4, C:3, D:2 Rationale: To stabilize the fetus, intrauterine resuscitation is the first priority, and to enhance fetal blood supply, the laboring client should be repositioned (1) to displace the gravid uterus and improve fetal perfusion. Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face mask (2) should be applied to the mother. Next, the IV fluids should be increased (3) to expand the maternal circulating blood volume. Then, the primary healthcare provider should be notified (4) for additional interventions to resolve the fetal stress.

A G1P0 patient's cervix is 4 cm dilated. She tells the nurse, "I'm in pain, but I'm afraid that medication might harm my baby." Which response by the nurse is the most therapeutic regarding pain medication during labor? a. "Pain medications do affect the baby, but so do pain and stress." b. "You are correct in your belief that medication might harm your baby." c. "The doctor has ordered only a small amount, so your baby will be quite safe." d. "The new medications are so much safer than the old medications."

Answer: a. "Pain medications do affect the baby, but so do pain and stress." Feedback: "Pain medications do affect the baby, but so do pain and stress" is the best response. Pain and stress can cause changes in the mother that can reduce the oxygen supply to the baby, whereas some medications are safe for the baby while allowing the mother to be more comfortable.

A nurse is caring for a patient during an amnioinfusion. Which fetal heart rate (FHR) pattern would be an expected outcome of a successful amnioinfusion? a. A decrease in variable decelerations. b. FHR pattern of 100-110 beats per minute. c. An increase in variable decelerations. d. FHR pattern of 160-180 beats per minute.

Answer: a. A decrease in variable decelerations. Feedback: Variable decelerations should decrease, not increase, following an amnioinfusion, because the fluid buffers the cord from being compressed. There should be no bradycardia or tachycardia.

A nurse is caring for a laboring patient who just received an epidural block. What is the major adverse effect for which the nurse should observe? a. Hypotension b. Unilateral block c. Hypertension d. Pruritus

Answer: a. Hypotension Feedback: Hypotension due to vasodilation from the initial effects of the epidural may be prevented with a preload bolus of 500 cc IV solution. Unilateral block and pruritus are less common adverse effects. Hypertension may be a complication of pregnancy-induced hypertension and oxytocin inductions.

The nurse is preparing to assist with administration of amnioinfusion (AI). Which of the following nursing interventions is appropriate? a. Obtain a solution of warmed, sterile normal saline b. Monitor the fetal heart rate through intermittent electronic fetal monitoring (EFM) c. Ensure that fluids infused into the uterus are not expelled d. Assist the patient with hourly ambulation

Answer: a. Obtain a solution of warmed, sterile normal saline Feedback: -Obtain a solution of warmed, sterile normal saline (true) -Monitor the fetal heart rate through intermittent electronic fetal monitoring (EFM) (false) -Ensure that fluids infused into the uterus are not expelled (false) -Assist the patient with hourly ambulation (false)

Regarding vaginal birth after cesarean (VBAC), which of the following statements is true? a. Prostaglandin agents are contraindicated in women attempting a VBAC b. After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts c. Research shows no significant correlation between maternal weight and successful VBAC d. Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth

Answer: a. Prostaglandin agents are contraindicated in women attempting a VBAC Feedback: -Prostaglandin agents are contraindicated in women attempting a VBAC (true) -After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts (false) -Research shows no significant correlation between maternal weight and successful VBAC (false) -Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth (false)

A nurse is reviewing the charts of four patients in the birthing unit. Which patient has an increased risk for an episiotomy? a. The patient laboring in a lithotomy position b. The patient with a fetus in an occiput-anterior position c. The patient with abruptio placentae d. The patient with pregnancy-induced hypertension

Answer: a. The patient laboring in a lithotomy position Feedback: A patient laboring in the lithotomy position or having a fetus in an occiput-posterior position would be at increased risk for having an episiotomy. A patient with abruptio placentae is at increased risk for a cesarean birth. Pregnancy-induced hypertension is not a risk factor having an episiotomy.

The nurse is caring for four laboring patients. Which patient would be an appropriate candidate for an epidural block? a. G1P0 dilated 2-3 cm b. G3P2 dilated 3-4 cm c. G2P0 dilated 1-2 cm d. G5P4 dilated 7-8 cm

Answer: b. G3P2 dilated 3-4 cm Feedback: The epidural block may be administered as soon as active labor is established (nullipara is 5-6 cm dilated, multipara is 3-4 cm) and the fetal vertex is engaged (zero station), which would be the G3P2 patient dilated to 3-4 cm. In a grand multipara (G5P4) dilated 7-8 cm, there would be insufficient time to place the epidural, as birth is imminent

A nurse is planning an educational seminar on medical (allopathic) vs. natural methods of cervical ripening. The nurse teaches that the medical method uses: a. Blue/black cohosh herbs. b. Misoprostol (Cytotec). c. Evening primrose oil. d. Sexual intercourse.

Answer: b. Misoprostol (Cytotec). Feedback: Misoprostol (Cytotec) is used in the allopathic method of cervical ripening, whereas blue/black cohosh herbs, primrose oil, and sexual intercourse are considered natural methods.

A nurse is caring for a patient with an oxytocin infusion. What is the correct nursing action prior to increasing the oxytocin rate? a. Assess cervical dilation b. Monitor fetal heart tones c. Evaluate the need for analgesia d. Assess maternal temperature

Answer: b. Monitor fetal heart tones Feedback: Monitoring fetal heart tones before increasing the oxytocin rate is crucial when caring for a patient with an oxytocin infusion. Assessing cervical dilatation is done after contractions have been established. When evaluating the need for analgesia, a vaginal exam should be performed to avoid giving the medication too early. Maternal blood pressure and pulse, not maternal temperature, should be measured to assess the effects of oxytocin.

A nurse in the birthing unit is caring for a patient following an amniotomy. What is an appropriate nursing intervention? a. Assess cervical dilation every two hours. b. Monitor temperature every two hours. c. Encourage ambulation every one to two hours. d. Replace expelled amniotic fluid every one to two hours.

Answer: b. Monitor temperature every two hours. Feedback: Due to an increased risk of infection, the nurse should monitor temperature every two hours following an amniotomy. Vaginal exams are kept to a minimum to decrease the chance of infection. Bed rest is maintained unless the presenting part is engaged. Replacing expelled amniotic fluid every one to two hours is unnecessary, as amniotic fluid is constantly produced.

The nurse educator is creating an inservice for student nurses who are completing their OB-GYN clinical rotation. When discussing misoprostol (Cytotec), which of the following components is incorrect and should be omitted from the educational content? a. The initial dosage of misoprostol for induction is 25 mcg b. Recurrent administration of misoprostol should exceed dosing intervals of more than 3 to 6 hours c. Pitocin should not be administered less than 4 hours after the last misoprostol dose d. Misoprostol should only be administered where uterine activity can be monitored continuously for an initial observation period

Answer: b. Recurrent administration of misoprostol should exceed dosing intervals of more than 3 to 6 hours Feedback: -The initial dosage of misoprostol for induction is 25 mcg (false—this is correct) -Recurrent administration of misoprostol should exceed dosing intervals of more than 3 to 6 hours (true—this is incorrect) -Pitocin should not be administered less than 4 hours after the last misoprostol dose (false—this is correct) -Misoprostol should only be administered where uterine activity can be monitored continuously for an initial observation period (false—this is correct)

A nurse is caring for a patient who received a spinal block for a cesarean birth. The patient asks the nurse when she can get up to go to the nursery. The nurse's best response is: "You will need to remain in bed for at least __________." a. 1 to 2 hours b. 24 hours c. 6 to 12 hours d. 3 to 4 hours

Answer: c. 6 to 12 hours Feedback: Temporary motor paralysis of the patient's legs will continue after birth. The patient will remain in bed for 6 to 12 hours after birth.

Butorphanol tartrate (Stadol) has been ordered for pain for a laboring patient. What should be the nurse's initial action prior to administering the medication? a. Monitor fetal heart rate. b. Assess cervical dilation. c. Assess for allergies. d. Monitor maternal vital signs

Answer: c. Assess for allergies. Feedback: Prior to administering butorphanol tartrate (Stadol) for pain, the nurse should assess for allergies. Monitoring fetal heart rate, assessing cervical dilation, and monitoring maternal vital signs are appropriate interventions, but not as the initial action.

A nurse is preparing a prenatal patient with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure? a. Mild labor contractions b. 34 weeks gestational age c. Reactive nonstress test d. Fetal breech must be engaged in the pelvis.

Answer: c. Reactive nonstress test Feedback: The fetus must be more than 36 weeks gestation, with a reactive nonstress test, and not engaged in the pelvis.

A nurse is caring for a laboring patient who just received systemic medication for labor pain. Which fetal heart rate pattern would require further action by the nurse? a. Increased fetal heart rate (FHR) variability and early decelerations b. Short-term variability is present. c. Variable decelerations d. Decreased FHR variability and late decelerations

Answer: d. Decreased FHR variability and late decelerations Feedback: The FHR pattern showing decreased FHR variability and late decelerations would alert the nurse to a serious problem. Increased fetal heart rate (FHR) variability and early decelerations are not an alarming pattern. Short-term variability is a normal finding.

A nurse is assisting the physician with a forceps-assisted birth. When should the nurse indicate for the physician to apply traction with the forceps? a. After a contraction b. Prior to a contraction c. After a decrease in fetal heart rate d. During a contraction

Answer: d. During a contraction Feedback: The nurse advises the physician when a contraction is present because traction is applied only with a contraction, not prior to or following a contraction. The patient should not be pushing during the application of forceps. Transient mild bradycardia resulting from head compression may occur as traction is applied to the forceps.

The nurse is caring for a laboring patient who is scheduled for an epidural block. What action by the nurse prior to the epidural placement would decrease the chance of maternal hypotension? a. Monitor maternal vital signs. b. Administer oxygen at 5 L/min. c. Reposition the patient every hour. d. Infuse an IV bolus of 500-1000 mL of normal saline.

Answer: d. Infuse an IV bolus of 500-1000 mL of normal saline. Feedback: Giving a 500 mL fluid bolus prior to the epidural will reduce the chance of maternal hypotension. Monitoring maternal vital signs would not decrease the chance of maternal hypotension. Administering O2 at 5 L/min is appropriate after hypotension has developed, to ensure proper oxygenation of the fetus, but it does not impact hypotension. Repositioning the patient every hour is a comfort measure that is appropriate throughout the administration of the block.

A G3P0 patient in active labor is admitted to the birthing center. Which data set should the nurse interpret as being within the normal range? a. Temperature 98.6°F and pulse 56 b. Temperature 98.4°F and blood pressure 142/90 c. Temperature 99.8°F and pulse 88 d. Temperature 99.4°F and blood pressure 130/88

Answer: d. Temperature 99.4°F and blood pressure 130/88 Feedback: During the first stage of labor, normal blood pressure is 90-140/60-90, pulse 60-90, respirations 12-20/minute, and temperature <37.6°C (99.6°F). Analysis; Physiological Integrity; Analysis

A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. Contraction pattern, amount of discomfort, and pregnancy history. b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. Identification of ruptured membranes, the woman's gravida and para, and her support person. d. Last food intake, when labor began, and cultural practices the couple desires.

B (All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices.)

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

B (An accelerated FHR is a positive sign; however, variable decelerations merit a vaginal examination. Vaginal examinations should be performed when the woman is admitted, when she perceives perineal pressure or the urge to bear down, when her membranes rupture, when a significant change in her uterine activity has occurred, or when variable decelerations of the FHR are noted.) Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? A. Help the patient to lie in supine position on the bed. B. Encourage the patient to sit in hands-and-knees position. C. Place a pillow under the patient's hip when lying in supine position. D. Ask the patient to lie in lateral position on the opposite side of the fetal spine.

B (The nurse should place the patient in a position that helps the rotation of the fetal occiput from a posterior to an anterior position. Therefore the nurse should encourage the patient to sit in hands-and-knees position, as it increases the pelvic diameter, allowing the head to rotate toward anterior position. The patient should not lie in supine position, as it may cause postural hypotension. Placing a pillow under the patient's hip when lying in supine position helps prevent supine hypotensive syndrome, but does not help in delivering the baby. The nurse should not ask the patient to lie in lateral position on the opposite side of the fetal spine, as it increases counter pressure on the back. Instead, lying in lateral position on the same side of the fetal spine will help the fetus rotate toward the posterior, as the gravity pulls the fetal back forward.) After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? A. Help the patient to lie in supine position on the bed. B. Encourage the patient to sit in hands-and-knees position. C. Place a pillow under the patient's hip when lying in supine position. D. Ask the patient to lie in lateral position on the opposite side of the fetal spine.

Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when: a. The woman has a sudden episode of vomiting. b. The nurse is unable to feel the cervix during a vaginal examination. c. Bloody show increases. d. The woman involuntarily bears down.

B (The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Vomiting, an increase in bloody show, and involuntary bearing down are only suggestions of second-stage labor.)

The nurse is assessing a pregnant patient in the last week of gestation. The nurse observes that the patient has flushed cheeks, uterine contractions (UCs) of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. What stage of labor should the nurse infer that the patient is in based on these observations? A. Latent phase B. Active phase C. Transition phase D. Active pushing phase

B (The patient has flushed cheeks, UCs of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. These symptoms are observed during the active phase of labor. The symptoms of the patient do not correlate with the latent, transition, or active pushing phases (second stage) of labor. In the latent phase of labor, the UCs are 30 to 45 seconds with a frequency of 5 to 30 minutes, and the mucus is pale pink. In the transition phase, the UCs are 45 to 90 seconds with a frequency of 2 to 3 minutes, and the mucus appears bloody. In the active pushing phase of the second stage of labor, the UCs are 90 seconds with a frequency of 2 to 2.5 minutes.)

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A) Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B) An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C) Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D) Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

B) An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. Rationale: A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor (B). Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the descent of the fetus. It is not difficult to empty the bladder during delivery (A). Urine specimens are obtained only by special order (C). There is danger of infection due to catheterization (D), but this is not the primary reason for encouraging the client to void during labor.

Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. A. Multiparous patients B. Nulliparous patients C. Patients needing forceps delivery D. Patients with fetal vertex presentation E. Patients with fetal breech presentatio

B, C, E (A nulliparous patient has rigid perineal tissue making it susceptible to injury. Fetal breech presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps delivery also increases the risk of injury due to undue stretch of the perineum. Multiparous patients have stretchable perineal tissues, which are less likely to get injured during childbirth. Fetal vertex presentation causes the least amount of tissue damage.)

The nurse is explaining to a student nurse how to determine fetal presentation and position by performing Leopold's maneuver. The nurse should explain that the second maneuver in this procedure is used to determine: A. Whether the fetal head or buttocks occupies the uterine fundus B. The location of the fetal back C. Whether the pelvic inlet contains the head or buttocks D. The descent of the presenting part into the pelvis

B. The location of the fetal back The second Leopold's maneuver determines the location of the fetal back. The first maneuver determines what part of the fetus is in the fundus. The third maneuver determines which fetal part is in the pelvic inlet. The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis.

While caring for a multiparous patient in the second stage of labor, the patient reports the urge to defecate. What is the best nursing intervention? A. Provide a bedpan to the patient to defecate. B. Place an enema in the rectum of the patient. C. Assess cervical dilation and station of the patient. D. Use running water to stimulate defection for the patient.

C (A multiparous patient feels an urge to defecate in the second stage of labor due to rectal pressure by the deeply descending presenting part in the pelvis. Rectal pressure may occur even in the absence of stool in the anorectal area. This often means that the patient is about to give birth to the child. Therefore the nurse has to perform vaginal examination of the patient to assess cervical dilation and station. The patient does not really defecate, so providing a bedpan is not necessary. Placing an enema in the rectum of the patient is not a suitable intervention, as it is done to increase peristalsis. Running water is used to stimulate voiding for the patient if there is a risk of urinary elimination. However, it is unrelated to the patient's urge of defecation.)

The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture. b. The cervix cannot be felt during a vaginal examination. c. The woman experiences a strong urge to bear down. d. The presenting part is below the ischial spines.

C (During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation.)

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is: a. Usually directly over the fetal abdomen. b. In a vertex position heard above the mother's umbilicus. c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally. d. In a breech position heard below the mother's umbilicus.

C (Nurses should be prepared for the shift. The PMI of the FHT usually is directly over the fetal back. In a vertex position it is heard below the mother's umbilicus. In a breech position it is heard above the mother's umbilicus.)

The nurse recognizes that a woman is in true labor when she states: a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

C (Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.)

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips. b. Determine the frequency by timing from the end of one contraction to the end of the next contraction. c. Evaluate the intensity by pressing the fingertips into the uterine fundus. d. Assess uterine contractions every 30 minutes throughout the first stage of labor.

C (The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus that may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses this assessment is performed more frequently.)

The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? A. To evaluate fetal status B. To know the onset of labor C. To assess for potential risk for infection D. To prevent fetal hypertension

C (When the membranes rupture, there is a possible risk of infection, as the microorganisms can ascend form the vagina to the uterus. Ruptured membranes can be assessed by monitoring the body temperature and vaginal discharge every 2 hours. The assessment is not used for knowing the onset of labor because it does not indicate the progress of labor. The fetal status is not known by the assessment of the temperature and vaginal show; it may be known by another procedure called Leopold maneuvers. This measure is not done to prevent fetal hypertension, because the maternal body temperature and vaginal discharge does not indicate fetal blood pressure.)

The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows that education was successful when the client states which of the following? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor." D) "During labor, the nurse will check my cervix by doing a pelvic exam every two hours."

C) During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This is the statement the client should make to prove that education was successful. Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. The client was asked specifically about assessing fetal status in labor. Although bloody show is monitored, doing so does not assess fetal status. Although contraction strength is palpated abdominally, the client was asked about assessing fetal status in labor.

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A) Insert an internal fetal monitor. B) Assess for cervical changes q1h. C) Monitor bleeding from IV sites. D) Perform Leopold's maneuvers.

C) Monitor bleeding from IV sites. Rationale: Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and bleeding, so these interventions are contraindicated.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? A) Heart rate of 100 beats/minute. B) Variable fetal heart rate. C) Onset of uterine contractions. D) Burning on urination.

C) Onset of uterine contractions. Rationale: Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions (C) places the client at risk for dilation and placental separation, which causes painless hemorrhaging. Although (A, B, and D) should be reported, the risk of hemorrhage is the priority.

The laboring client presses the call light and reports that her water has just broken. What would the​ nurse's first action​ be?

Check fetal heart tones.

The primigravida in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the: 1. "Absence of variable decelerations." 2. "Presence of variability." 3. "Fetal heart rate baseline." 4. "Depth of decelerations."

Correct Answer: 2 Rationale 1: Variable decelerations indicate cord compression. Rationale 2: Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. Rationale 3: The fetal heart rate baseline does not indicate central nervous system function. Rationale 4: The depth of decelerations does not indicate central nervous system function.

The nurse is preparing to assess a laboring primiparous patient who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed? 1. "You are going to do a vaginal exam to see how far dilated my cervix is." 2. "The reason for a pelvic exam is to determine how low in the pelvis my baby is." 3. "When you check my cervix, you will find out how thinned out it is." 4. "After you assess my pelvis, you will be able to tell when I will deliver."

Correct Answer: 4 Rationale 1: Cervical dilation is one aspect of the pelvic exam assessment. Rationale 2: Determining the station of the presenting part is one aspect of the pelvic exam assessment. Rationale 3: Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment. Rationale 4: An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about the contractions. The nurse will not have enough information following the cervical exam to estimate time of birth.

A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately: 1. Change the patient's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.

Correct Answer: 4 Rationale 1: Changing the patient's position is not indicated. Rationale 2: Meconium-stained amniotic fluid does not indicate that birth is imminent. Rationale 3: Oxygen administration is not indicated. Rationale 4: Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring.

While orienting a new nurse to the obstetrics unit, the R.N. preceptor is describing how to determine the baseline (BL) fetal heart rate (FHR). Which statement should the R.N. preceptor include in order to accurately describe the BL FHR? 1. "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute is the baseline rate." 2. "The baseline FHR should include periodic or episodic changes in FHR." 3. "Normal baseline FHR ranges from 100 to 180 beats per minute." 4. "The baseline FHR excludes periods of marked variability."

Correct Answer: 4 Rationale 1: The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5 beats per minute (bpm). Rationale 2: The baseline FHR excludes periodic or episodic changes and periods of marked variability. Rationale 3: Normal FHR (baseline rate) ranges from 110 to 160 beats per minute. Rationale 4: The baseline FHR excludes periodic or episodic changes and periods of marked variability.

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? 1. Alert the physician/CNM of the fetal status. 2. Administer oxygen to the patient at 4 liters per minute via nasal cannula. 3. Decrease the rate of infusion of intravenous fluids. 4. Facilitate a maternal left lateral position.

Correct Answer: 4 Rationale 1: While the attending physician or CNM should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct patient care. Initially, the mother should be placed in the left lateral position. Rationale 2: Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 liters per minute via facemask. Rationale 3: Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids. Rationale 4: In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow.

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: A. Also involves the anterior rectal wall. B. Continues through the anal sphincter muscle. C. Extends through muscles of the perineal body. D. Extends through the skin and structures superficial to muscles

D (A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.)

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A) A gravida 6, para 5 who is 38 years of age and in early labor. B) A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C) A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D) A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

D) A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. Rationale: When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation. (A, B, and C) do not present problems with administration of an enema.

The nurse palpates the abdomen of a pregnant patient and reports that the fetus lies in longitudinal position with cephalic presentation. Which observation enabled the nurse to report about the fetal position? A. The presenting part has deeply descended in the pelvis. B. The cephalic prominence is on the same side as the back. C. The head is presenting to the true pelvis and is not engaged. D. The head feels round, firm, freely movable, and palpable by ballottement

D (Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. The head feels round, firm, freely movable, and palpable by ballottement when the fetus has a cephalic or breech presentation. Based on the descent of the presenting part, it may be difficult to infer the fetal position, as the presenting part can be head or buttock. The cephalic prominence on the same side as the back shows that the fetal head is extended and the face is the presenting part. This maneuver is not related to identification of fetal position. If the head is presenting to the true pelvis and is not engaged, then it determines the attitude of fetal head whether flexed or extended. It does not indicate the fetal position.)

During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? A. Palpate the fetal head with the palmar surface of the fingertips of the right hand. B. Identify the fetal part that occupies the fundus in the uterus of the pregnant patient. C. Palpate the smooth convex contour of the fetal back using the palmar surface of one hand. D. Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly.

D (Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. Therefore the nurse should grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly in order to determine whether the fetal head is flexed or extended. Identifying the fetal part that occupies the fundus of the patient helps to identify the fetal position. The fetal head is palpated with the palmar surface of the fingertips using both hands, but not with only the right hand to determine the cephalic prominence. Palpation of the smooth convex contour of the fetal back and irregularities using the palmar surface of one hand is not used to determine the attitude of the fetal head. This maneuver helps identify the feet, hands, and elbows of the fetus.)

Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)? a. A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. A reddish-haired mother of two who is going through a breech birth c. A dark-skinned, first-time mother who is going through a long labor d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician

D (Reddish-haired women have tissue that is less distensible than that of darker-skinned women and therefore may have less efficient healing. First time mothers are also more at risk, especially with breech births, long second-stage labors, or rapid labors in which there is insufficient time for the perineum to stretch. The rate of episiotomies is higher when obstetricians rather than midwives attend births.)

The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicates the reason for slow progress in labor? A. "I have a family history of diabetes and hypertension." B. "I stopped taking folic acid supplements a week ago." C. "I have been on a diet with high amounts of protein for 15 days." D. "I am worried a lot this time; I had a lot of problems in my last labor."

D (The nurse suspects that the patient may have slow progress in labor after knowing that the patient is worried and stressed, because she had complications in the previous labor. Stress may reduce the progress in the labor by decreasing the levels of catecholamines. This, in turn, reduces the UCs. Family history of diabetes does not affect the labor progression or UCs. Folic acid supplements are necessary for fetal growth and are given early in pregnancy to prevent neural tube defects. They do not affect the birth process. Taking a diet with a high amount of protein may not affect the onset of labor. Moreover, it helps in the fetal growth and development.)

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate and pattern.

D (The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.)

As compared with admission considerations for an adult woman in​ labor, the​ nurse's priority for an adolescent in labor would be which of the​ following?

Developmental level

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A) Cervical dilation of 5 cm with 90% effacement. B) White blood cell count of 12,000/mm3. C) Hemoglobin of 12 mg/dl and hematocrit of 38%. D) A platelet count of 67,000/mm3.

D) A platelet count of 67,000/mm3. Rationale: Thrombocytopenia (low platelet count) (D) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administred. (A, B, and C) are within the normal parameters for a client in active labor and is not contraindicated for the placement of an epidural.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A) Check the client for urinary bladder distention. B) Notify the healthcare provider of the nonreactive results. C) Have the mother stimulate the fetus to move. D) Ask the client if she has felt any fetal movement.

D) Ask the client if she has felt any fetal movement. Rationale: The client should be asked if she has felt the fetus move (D). An NST is used to determine fetal well-being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to fetal movement. The client should empty her bladder before starting the test, but bladder distention does not impede fetal movement (A). The client should be quizzed about fetal movement before determining that the NST is nonreactive (B). If no movement has occurred in the last 20 to 30 minutes, it is likely that the fetus is sleeping--providing the mother with orange juice often wakes the infant, and then the NST should be conducted again.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? A) Give the medication as prescribed and monitor for efficacy. B) Encourage the client to breastfeed rather than bottle feed. C) Have the client empty her bladder and massage the fundus. D) Call the healthcare provider to question the prescription

D) Call the healthcare provider to question the prescription. Rationale: Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D). (A) compromises patient safety. While (B) releases endogenous oxytocin, and (C) promotes uterine contraction, questioning the administration of Methergine is a higher priority because it concerns medication safety.

The nulliparous client asks the nurse why the cervix has only dilated from 1 to 2 cm in 3 hours of contractions, occurring every 5 minutes. What is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

D) Cervical effacement must be nearly complete before cervical dilation takes place in primiparas. This is why the labor and birth of a first baby usually take much more time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.

During the fourth stage of labor, a client's blood pressure is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.

D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.

The laboring client is complaining of tingling and numbness in her fingers and​ toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the​ following?

Hyperventilation

The laboring client is at 7​ cm, with the vertex at a​ +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal​ classes, and they have planned on a​ natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes.​ Now, during​ contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the​ client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this​ client?

Pain, Acute, related to uterine​ contractions, cervical​ dilatation, and fetal descent

A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most​ helpful?

Stand next to the bed with hands on the railing next to the client.

What assessment finding does the nurse expect in a woman with cervical dilation and effacement? a. Bloody show b. False labor c. Lightening d. Bladder distention

a. Bloody show

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Engagement b. Extension c. Internal rotation d. External rotation

a. Engagement

A woman who is gravida 3 para 2 enters the intrapartum unit. Which nursing assessments take priority at this time? (Select all that apply.) a. Fetal heart rate b. Maternal vital signs c. The woman's nearness to birth d. Contraction patterns e. Last food and water intake

a. Fetal heart rate b. Maternal vital signs c. The woman's nearness to birth

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. What is the Apgar score for this infant? a. 7 b. 8 c. 9 d. 10

c. 9

A 25-year-old primigravida is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly the woman pushes her husband's hand away and shouts, "Don't touch me!" What action by the nurse is most appropriate? a. Reassure the husband this is normal in the transition phase. b. Ask the woman if she needs some pain medication. c. Call the anesthesia provider for an epidural block. d. Ask the husband to leave the room for a few minutes.

a. Reassure the husband this is normal in the transition phase.

On assessment, a labor patient is noted to have frothy sputum, a heart rate of 110, and large amount of continuous vaginal bleeding. The nurse should suspect? a. Amniotic fluid embolus b. Placental abruption c. DIC d. Congestive heart failure

a. amniotic fluid embolus These are symptoms of an amniotic fluid embolus and cor pulmonale. Placental abruption does not have any of the symptoms. DIC may have hemorrhage associated with it but not the other symptoms. Congestive heart failure would not have vaginal bleeding with it.

During the active phase of labor, the FHR of a low-risk patient should be assessed every a. 10 to 15 minutes. b. 15 to 30 minutes. c. 30 to 45 minutes. d. 1 hour.

b. 15 to 30 minutes.

Which maternal factor may inhibit fetal descent and require further nursing interventions? a. Decreased peristalsis b. A full bladder c. Reduction in internal uterine size d. Rupture of membranes

b. A full bladder

The nurse assesses a patient whose cervix is dilated to 5 cm. What phase of labor does the nurse recognize the woman to be in? a. Latent phase b. Active phase c. Second stage d. Third stage

b. Active phase

Thirty minutes after giving birth a woman's uterus feels boggy to the nurse. The nurse massages the fundus without change. What action does the nurse take next? a. Notify the provider or nurse-midwife immediately. b. Assess the woman for a full bladder. c. Prepare to administer oxytocin. d. Take a full set of vital signs.

b. Assess the woman for a full bladder.

A student nurse is trying to assess vital signs on a laboring woman. Which statement by the registered nurse is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.

b. Maternal circulating blood volume increases temporarily during contractions.

To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the a. increment. b. acme. c. decrement. d. interval.

b. acme.

When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline. What is the likely position of the fetus? a. ROA b. LSP c. RSA d. LOA

c. RSA

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucous discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

c. The vulva bulges and encircles the fetal head.

The nurse is admitting a laboring client with a breech presentation to the birthing unit. Where is the most appropriate place for the nurse to auscultate for fetal heart tones? a. Below the umbilicus b. Midline of the umbilicus c. Above the umbilicus d. Lower right maternal quadrant

c. above the umbilicus Auscultate for fetal heart tones above the umbilicus for a breech presentation, bacelow the umbilicus for a cephalic presentation.

During labor, a vaginal examination should be performed only when necessary because of the risk of a. fetal injury. b. discomfort. c. infection. d. perineal trauma.

c. infection.

The nurse knows that hypertonic labor contractions, if unresolved, may develop into? a. Late decelerations b. Persistent occiput posterior c. Prolonged latent phase d. Precipitous delivery

c. prolonged latent phase Hypertonic contractions are ineffective in dilating the cervix and without intervention will manifest into a prolonged latent phase.

What finding should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Contractions lasting 90 seconds c. FHR in the 140s d. Meconium-stained amniotic fluid

d. Meconium-stained amniotic fluid

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 unchanged from admission. Membranes are intact. What action by the nurse is most appropriate? a. Prepare the woman for a cesarean birth. b. Admit the woman for extended observation. c. Discharge the woman with a sedative so she can rest. d. Provide discharge teaching on signs of true labor.

d. Provide discharge teaching on signs of true labor.

To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by a. contracting the lower uterine segment. b. enlarging the internal size of the uterus. c. promoting blood flow to the cervix. d. pulling the cervix over the fetus and amniotic sac.

d. pulling the cervix over the fetus and amniotic sac.

oxytocin used after birth to do what?

stimulate contractions of the uterus and decrease risk for PPH

The client is being admitted to the birthing unit. As the nurse begins the​ assessment, the​ client's partner asks why the​ fetus's heart rate will be monitored. After the nurse​ explains, which statement by the partner indicates a need for further​ teaching?

​"By listening to the​ heart, we can tell the gender of the​ fetus."

The student nurse learns that which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Descent b. Engagement c. Flexion d. Station

c. Flexion

The primary difference between the labor of a nullipara and that of a multipara is the a. amount of cervical dilation. b. total duration of labor. c. level of pain experienced. d. sequence of labor mechanisms.

b. total duration of labor.

The nurse is answering phone calls in the OB triage area. Which patient should the nurse advise to come to the hospital soonest after labor begins? a. Gravida 2 para 1 who lives 10 minutes away b. Gravida 1 para 0 who lives 40 minutes away c. Gravida 3 para 2 whose longest previous labor was 4 hours d. Gravida 2 para 1 whose first labor lasted 16 hours

c. Gravida 3 para 2 whose longest previous labor was 4 hours

The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products a. continues except when placental functions are reduced. b. increases as blood pressure decreases. c. diminishes as the spiral arteries are compressed. d. is not significantly affected.

c. diminishes as the spiral arteries are compressed.

A​ first-time 22-year-old single labor​ client, accompanied by her​ boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of​ labor?

1) Coping: Family,​ Compromised, related to labor process 2) Pain, Acute, related to uterine​ contractions, cervical​ dilatation, and fetal descent 3)Fear/Anxiety related to discomfort of labor and unknown labor outcome

The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during​ labor?

1)They are a source of relaxation. 2)They increase the ability to cope with contractions. 3)They are a source of distraction. 4)They increase a​ woman's pain threshold.

The nurse has completed the physical assessment of a client in early​ labor, and proceeds with the social assessment. A social history of the client would include which of the​ following?

1)Use of drugs and alcohol 2)Family violence or sexual assault 3)Current living situation 4)Availability of resources

he laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a​ -2 station. The cervix is 6 cm and​ 100% effaced. The membranes spontaneously ruptured prior to​ admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest​ priority?

Keep the client on bed rest at this time.

An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to do which of the​ following?

Offer to remain with his partner while he takes a break.

The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this​ client?

Offer to teach the partner how to massage tense muscles.

A client is admitted to the labor and delivery unit with contractions that are​ regular, are 2 minutes​ apart, and last 60 seconds. She reports that her labor began about 6 hours​ ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex​ presenting, with the cervix​ 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of​ labor?

Transition phase

What nursing intervention is the priority when caring for a laboring woman? a. Helping the woman find ways to manage the pain b. Eliminating the pain associated with labor c. Sharing personal experiences regarding labor and delivery d. Providing the woman food to restore her energy

a. Helping the woman find ways to manage the pain

The nurse is caring for a woman whose fetus has a breech presentation. What complication does the nurse prepare to assist with? a. Umbilical cord compression b. More rapid labor c. A high risk of infection d. Maternal perineal trauma

a. Umbilical cord compression

Leopold's maneuvers are used by practitioners to determine a. the best location to assess the fetal heart rate (FHR). b. cervical dilation and effacement. c. whether the fetus is in the posterior position. d. if the woman needs an amniotomy.

a. the best location to assess the fetal heart rate (FHR).

The nurse teaching a prenatal class explains that which is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes

b. Cervical dilation and effacement

normal labor process contractions should be how many mins apart

Not less than 2 minutes

The nurse who elects to practice in the area of obstetrics learns about the "four Ps." What are the "five Ps"? a. Powers b. Passage c. Position d. Passenger e. Psyche f. Purpose

A,B,C,D,E

Before applying a cord​ clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse​ reply?

I'm checking the blood vessels in the cord to see whether it has two arteries and one​ vein."

The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in three hours of contractions occurring every five minutes. The best response by the nurse is: A. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." B. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." C. "What did you expect? You've only had contractions for a few hours. Labor takes time." D. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."

A. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much less time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected now. Although it is true that this patient has only been in early labor for a short time, and it is true that labor for a primip averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.

The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? A. Assist the patient to change from Fowler's to left lateral position B. Apply oxygen to the patient at 2 liters per nasal cannula C. Notify the operating room of the need for a cesarean birth D. Determine the color of the leaking amniotic fluid

A. Assist the patient to change from Fowler's to left lateral position The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the patient might get the fetus off the cord and eliminate the variable decelerations. Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable. There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations. The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody.

A healthy 18-year-old patient who is 40 weeks' gestation presents at the clinic complaining of vaginal expulsion of stringy mucus followed by blood-tinged secretions. She denies any discomfort or any other changes. Based upon the patient's complaints, what is most likely to occur within the next 24 to 48 hours? A. Onset of labor B. Spontaneous abortion C. Cesarean section D. Chorioamnionitis

A. Onset of labor Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged secretions are called bloody show. Bloody show is considered a sign that labor will begin within 24 to 48 hours. The patient is most likely demonstrating expulsion of the mucous plug and bloody show, which is considered a sign that labor will begin within 24 to 48 hours. The patient is describing pregnancy-related changes associated with imminent onset of labor. Based upon her report, there is no indication that cesarean section will be necessary. Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM). Based upon the patient's report, she is demonstrating mucus plug expulsion and bloody show.

The nurse is preparing to assess the fetus of a laboring patient. Which assessment should the nurse perform first? A. Perform Leopold's maneuver to determine fetal position B. Count the fetal heart rate for 30 seconds and multiply by two C. Dry the maternal abdomen before using the Doppler D. Place the patient into a left lateral position

A. Perform Leopold's maneuver to determine fetal position This is the first step so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold's maneuver to determine fetal position so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided. Prior to using the Doppler device, a water-based gel is applied to the skin. The fetal heart tone assessment should be performed while the patient is either supine with a lateral tilt or while in left lateral position. Leopold's maneuver is performed first to determine where to listen for fetal heart tones.

The nurse is caring for laboring patients. Which women are experiencing problems related to a critical factor of labor? (Select all that apply.) A. Primip at 7 cm, fetus in military attitude B. Multip at 3 cm, fetus in longitudinal lie C. Primip at 4 cm, fetus with macrocephaly due to hydrocephalus D. Multip at 6 cm, fetus at −2 station, mild contractions E. Primip at 5 cm, fetal presenting part is right shoulder

A. Primip at 7 cm, fetus in military attitude C. Primip at 4 cm, fetus with macrocephaly due to hydrocephalus D. Multip at 6 cm, fetus at −2 station, mild contractions E. Primip at 5 cm, fetal presenting part is right shoulder Attitude refers to the relationship of the fetal parts to one another. Military attitude is an unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger diameter of the head fitting through the pelvis. This patient is experiencing a problem between the maternal pelvis and the presenting part. Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies might not fit through the bony pelvis and could require birth by cesarean. This patient is experiencing a problem between the maternal pelvis and the presenting part. Station refers to how low in the pelvis the baby's presenting part is; −2 station is high in the pelvis. Contractions should be strong to cause fetal descent and cervical dilation. Mild contractions will not move the baby down or open the cervix. This patient is experiencing a problem between the maternal pelvis and the presenting part. The presenting part is the fetal part coming through the cervix. The occiput or back of the baby's head is the most common and most effective presenting part. A shoulder presentation cannot deliver vaginally and will require a cesarean birth. This patient is experiencing a problem between the maternal pelvis and the presenting part. Lie refers to the relationship between the cephalocaudal axis of the mother to the cephalocaudal axis of the fetal body; longitudinal lie is normal.

A laboring patient complains of numbness of nose, fingers, and toes, and spots before her eyes. What should be the initial action by the nurse? a. Implement seizure precautions. b. Encourage slow, shallow breaths. c. Administer oxygen at 5 L per minute. d. Notify the physician or midwife.

Answer: b. Encourage slow, shallow breaths. Feedback: Encourage slow, shallow breaths should be the initial action by the nurse for a laboring patient who complains of symptoms of hyperventilation (hypocarbia). Slow, shallow breathing will help her build up her CO2 level to balance out her excessive oxygen levels. Implementing seizure precautions, administering oxygen, and notifying the physician or midwife are not appropriate nursing actions for hyperventilation.

A G1P0 patient at 39 weeks gestation arrives at the birthing center with irregular contractions ranging from 10-30 minutes apart. Assessment data reveals 1-2 cm cervical dilation, membranes intact, and a thick cervix. What would be the most appropriate nursing action at this time? a. Send the patient home to ambulate. b. Admit the patient to the birthing center. c. Begin to hydrate the patient with IV fluids. d. Monitor the patient with pelvic checks every hour.

Answer: a. Send the patient home to ambulate. Feedback: A patient with contractions 10-30 minutes apart and 1-2 cm cervical dilation, membranes intact, and a thick cervix is in the latent phase of early labor. Send the patient home to ambulate. The patient will be admitted only when she begins active labor. Beginning to hydrate the patient with IV fluids is not appropriate; there is no dehydration status or preterm labor. Monitoring the patient with pelvic checks every hour is not appropriate until active labor and progress has been made.

The primiparous patient at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? A. "Unless you have pain with urination, we don't need to worry about it." B. "These symptoms usually mean the baby's head has descended further." C. "Come in for an appointment today and we'll check everything out." D. "This might indicate that the baby is no longer in a head down position."

B. "These symptoms usually mean the baby's head has descended further." This is the best response because it most directly addresses what the patient has reported. Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. There is no need for an additional appointment, as increased pelvic pressure and urinary frequency are premonitory signs of labor. The patient is experiencing premonitory signs of labor; the fetus changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis.

The primigravida in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the: A. "Absence of variable decelerations." B. "Presence of variability." C. "Fetal heart rate baseline." D. "Depth of decelerations."

B. "Presence of variability." Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. Variable decelerations indicate cord compression. The fetal heart rate baseline does not indicate central nervous system function. The depth of decelerations does not indicate central nervous system function.

Which patient requires immediate intervention by the labor and delivery nurse? A. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg B. Primip that delivered one hour ago with WBC of 50,000 C. Multip at 5 cm with a respiratory rate of 22 between contractions D. Primip in active labor with urine output of 100 ml/hour

B. Primip that delivered one hour ago with WBC of 50,000 A white count of 25,000-30,000 is normal at the end of labor and during the early postpartum period. This white count is abnormally high and requires further assessment and provider notification. The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor. The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This patient requires no further intervention. This is a normal urine output and requires no further intervention.

The laboring primiparous patient with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? "The monitor: A. "Is necessary so we can see how your labor is progressing." B. "Will prevent complications from the meconium in your fluid." C. "Helps us to see how the baby is tolerating labor." D. "Can be removed, and oxygen can be given instead."

C. "Helps us to see how the baby is tolerating labor." This is the reason fetal monitoring is used. The fetal monitor does not help visualize labor progress. Labor progress is assessed through the pelvic exam, checking to see if the cervix is dilating and the fetus descending into the pelvis. The fetal monitor will provide information on how the baby is tolerating labor, but it does not prevent complications such as meconium aspiration syndrome. Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Fetal monitoring provides information on the status of the fetus, and it is a necessary assessment when the amniotic fluid is meconium-stained.

The primiparous patient at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? A. "You shouldn't work so much at this point in pregnancy." B. "What you are describing is not commonly experienced in the last weeks." C. "Your body may be telling you it is going into labor soon." D. "If the bladder pressure continues, come in to the clinic tomorrow."

C. "Your body may be telling you it is going into labor soon." One of the premonitory signs of labor includes lightening: The baby drops lower into the pelvis, which creates increased pelvic and bladder pressure but less pressure on the diaphragm, which makes breathing easier. There is no indication that the patient should decrease her work schedule. Lightening is a common and expected finding. Lightening does not indicate pathology, and therefore there is no need to come to the clinic if the symptoms continue.

The student nurse is to perform Leopold's maneuver on a laboring patient. Which assessment requires intervention by the staff nurse? A. The patient is assisted into supine position, and the position of the fetus is assessed B. The upper portion of the uterus is palpated, and then the middle section C. After determining where the back is located, the cervix is assessed D. Following voiding, the patient's abdomen is palpated from top to bottom

C. After determining where the back is located, the cervix is assessed The cervical exam is not a part of Leopold's maneuvers abdominal palpation is the only technique used for Leopold's maneuver. Determination of fetal position and station is the point of Leopold's maneuver. The patient is supine to facilitate uterine palpation. The patient is instructed to void prior to beginning Leopold's maneuver to facilitate comfort; Leopold's maneuver is essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix.

The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient's history requires notifying the physician? A. Blood pressure 120/88 B. Father is a carrier of sickle-cell trait C. Dark red vaginal bleeding D. History of domestic abuse

C. Dark red vaginal bleeding Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus. Blood pressure 120/88. Although the diastolic reading is slightly elevated, this is not the top priority. The infant also might have sickle trait, but sickle trait is not life-threatening at this time. This patient is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the patient.

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? A. Increased pulse B. Elevated blood pressure C. Muscle tension D. Increased respirations

C. Muscle tension Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress. Increased pulse is a manifestation of pain, but it does not impede labor. Elevated blood pressure is a manifestation of pain, but it does not impede labor. Increased respiration is a manifestation of pain, but it does not impede labor.

The nurse is preparing to assess a laboring primiparous patient who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed? A. "You are going to do a vaginal exam to see how far dilated my cervix is." B. "The reason for a pelvic exam is to determine how low in the pelvis my baby is." C. "When you check my cervix, you will find out how thinned out it is." D. "After you assess my pelvis, you will be able to tell when I will deliver."

D. "After you assess my pelvis, you will be able to tell when I will deliver." An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about the contractions. The nurse will not have enough information following the cervical exam to estimate time of birth. Cervical dilation is one aspect of the pelvic exam assessment. Determining the station of the presenting part is one aspect of the pelvic exam assessment. Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment.

A 25-year-old woman is 38 weeks' gestation with her first pregnancy. For the third time in one week, she presents to the hospital with complaints that are determined to be suggestive of false labor. Prior to discharge, the patient states, "I'm so embarrassed for thinking I was in labor. I feel like a fool." What is the nurse's best response? A. "We'll discuss the differences between true labor and false labor so this doesn't happen again." B. "It's impossible to distinguish between false labor and true labor." C. "Don't feel bad. Everyone makes mistakes sometimes." D. "It's very difficult to tell the difference between true and false labor. Please know we're here to take care of you whenever you need us."

D. "It's very difficult to tell the difference between true and false labor. Please know we're here to take care of you whenever you need us." Rather than reinforcing the woman's incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman's embarrassment. While it may be difficult to subjectively distinguish between false labor and true labor, vaginal examination can be performed to determine if cervical dilatation is occurring. Instead of reinforcing the woman's perception of having made an error, the nurse should reassure her that her embarrassment is unwarranted.

While orienting a new nurse to the obstetrics unit, the R.N. preceptor is describing how to determine the baseline (BL) fetal heart rate (FHR). Which statement should the R.N. preceptor include in order to accurately describe the BL FHR? A. "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute is the baseline rate." B. "The baseline FHR should include periodic or episodic changes in FHR." C. "Normal baseline FHR ranges from 100 to 180 beats per minute." D. "The baseline FHR excludes periods of marked variability."

D. "The baseline FHR excludes periods of marked variability." The baseline FHR excludes periodic or episodic changes and periods of marked variability. The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5 beats per minute (bpm). Normal FHR (baseline rate) ranges from 110 to 160 beats per minute.

During the fourth stage of labor, your patient's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to: A. Turn the patient onto her left side B. Place the bed in Trendelenburg position C. Massage the fundus D. Continue to monitor

D. Continue to monitor The patient's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.

While caring for a labor patient, the nurse determines during a vaginal exam that the baby's head has internally rotated. This information is given to the family. The labor support person asks the nurse, "What other position changes will the baby undertake during labor and birth?" How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation? A. Flexion, extension, restitution, external rotation, and expulsion B. Expulsion, external rotation, and restitution C. Restitution, flexion, external rotation, and expulsion D. Extension, restitution, external rotation, and expulsion

D. Extension, restitution, external rotation, and expulsion The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? A. Alert the physician/CNM of the fetal status B. Administer oxygen to the patient at 4 liters per minute via nasal cannula C. Decrease the rate of infusion of intravenous fluids D. Facilitate a maternal left lateral position

D. Facilitate a maternal left lateral position In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow. While the attending physician or CNM should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct patient care. Initially, the mother should be placed in the left lateral position. Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 liters per minute via facemask. Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids.

The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The patient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? A. Leave the patient alone so she can rest B. Ask the family to take a coffee and snack break C. Encourage the patient to have an epidural for pain D. Reassure the patient that she will not be left alone

D. Reassure the patient that she will not be left alone Because the patient is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the patient and reassuring her that she will not be alone are the highest priorities at this time. The patient is in the transitional phase of the first stage of labor and will not want to be alone. There is no indication that the patient wants pain relief.

Which of the following, if seen on an electronic fetal monitoring strip, would the nurse explain to a laboring patient as a change in the baseline fetal heart rate? A. Acceleration B. Late deceleration C. Sinusoidal pattern D. Tachycardia

D. Tachycardia Bradycardia and tachycardia are changes in the fetal heart rate baseline. Accelerations, late deceleration, and sinusoidal patterns are periodic changes of the fetal heart rate.