intrapartum period

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Who will be with you during labor?" "Do you have any chronic illnesses?" "What is your expected due date?" "Do you have any allergies?"

"What is your expected due date?" Explanation: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.

A client who's a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. Cervical examination is likely to reveal the client is 4 to 5 cm dilated; 80% effaced at -1 station. 2 cm dilated; 50% effaced at +1 station. 2 cm dilated; 100% effaced at 0 station. 3 cm dilated; 50% effaced at 0 station.

2 cm dilated; 100% effaced at 0 station. Explanation: Because the client is a gravida, cervical examination is likely to reveal that she's 2 cm dilated, 100% effaced, and at 0 station. Multigravidas efface and dilate at the same time, whereas primigravidas will efface and then dilate.

A client who has abruptio placentae exhibits cyanosis in the earlobes, capillary filling time >3 seconds, and reports "heartburn." Which is the best nursing intervention? Notify the healthcare provider immediately. Increase the temperature of the room and provide warmed blankets. Elevate the head of the bed. Assess for vaginal bleeding.

Notify the healthcare provider immediately. Explanation: The manifestations of earlobe cyanosis, capillary filling time >3 seconds, and gastric distress in this client may indicate disseminated intravascular coagulation. The healthcare provider should be notified immediately. Increasing the ambient temperature may increase client comfort, and an assessment of vaginal bleeding is indicated. Sitting the client up in bed is not indicated.

A 24-year-old primigravid client in active labor asks to use the jet hydrotherapy tub to aid in pain relief. Which condition would the nurse consider to be a contraindication for hydrotherapy? hypotonic labor patterns multifetal gestation diabetes mellitus ruptured membranes

ruptured membranes Explanation: Some health care providers (HCPs) do not allow clients with ruptured membranes to use a hot tub or jet hydrotherapy tub during labor for fear of infections. The temperature of the water should be between 98°F and 100°F (36.7°C and 37.8°C) to prevent hyperthermia. Jet hydrotherapy is not contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns.

A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take? Administer oxygen via facemask at 10 to 12 L/minute. Document fetal well-being. Notify the health care provider (HCP) of the situation. Turn the client to her left side.

Document fetal well-being. Explanation: Accelerations that are episodic and occur during fetal movement demonstrate fetal well-being. Turning the client to the left side, applying oxygen by face mask and notifying the HCP are interventions used for late and variable decelerations indicating the fetus is not tolerating the induction process well.

A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? painful contractions every 3 to 5 minutes leaking amniotic fluid clear in color fetal descent into the pelvic inlet cervical dilation and effacement

cervical dilation and effacement Explanation: True labor is present when cervical dilation and effacement occur. Fetal descent into the pelvic inlet is an indication that labor will begin soon. However, for a nulligravid client, this may take 1 to 2 weeks. Painful contractions every 3 to 5 minutes may be Braxton Hicks contractions. Contractions that disappear when the client lies down are a sign of false labor. Although leaking amniotic fluid should be reported, it is not a sign of true labor.

What assessment data of a laboring woman would require further intervention by the nurse? fetal heart rate (FHR) 150 beats/minute maternal heart rate 125 beats/minute temperature of 99.1° F (37.27° C) moderate contractions 3 minutes apart

maternal heart rate 125 beats/minute Explanation: All data are normal except for the maternal heart rate of 125 beats/minute. Normal maternal heart rate is 60-100 beats/minute. The elevated heart rate is a possible signal of developing complications.

A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action? Notify the physician that the partner has been waiting to discuss the mother's condition. Reassure the partner that the mother's condition is stable at present. Ask the partner if there is any family support that can come to the hospital. Tell the partner that the physician is very busy and will come when available.

perineum Explanation: A pudendal block is used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the back, abdomen, or fundus.

After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which event occurs? A sudden gush of dark blood appears. The uterus enlarges. The client expends efforts pushing. The uterus becomes oval shaped.

A sudden gush of dark blood appears. Explanation: A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and changing of the uterus to a round or spherical shape are impending signs of placental separation. Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion.

The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention? Initiate oxytocin infusion. Assess for rupture of the membranes. Prepare for birth of the neonate. Call anesthesia to give epidural anesthesia.

Prepare for birth of the neonate. Explanation: A client who is fully dilated is about to begin pushing. Appropriate actions for this time include assessing vital signs every 15 minutes, positioning for effective pushing, and preparing for delivery. Oxytocin is administered to induce labor or to help the uterus contract after birth; it would be inappropriate to administer to a client entering the second stage of labor. It is inappropriate to insert an epidural when the client is ready to start pushing. Status of membranes would have been determined during the sterile vaginal exam.

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? persistent fetal bradycardia late decelerations fetal heart rate variability within 5 to 10 beats/minute variable decelerations and sinusoidal pattern

fetal heart rate variability within 5 to 10 beats/minute Explanation: Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered normal. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — an abnormal pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol? Note the time and a detailed description of the individual. Check to make sure each neonate is with its parent. Call security personnel to remove the visitor. Stop the visitor, and ask for identification.

Stop the visitor, and ask for identification. Explanation: Labor and delivery units are locked to prevent neonate abduction. All visitors should be stopped at the door, identified, and matched to a current client. If an unidentified visitor gains entry without having gone through this process, it is appropriate to stop the person to ask for identification and confirm who the visitor is there to see. Calling security, making sure that each neonate is with its parent and noting the time and a description of the individual would not be the priority actions in this case; but rather what one would do for an attempted abduction.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse? Instruct the client to call her physician. Explain to the client that she should lie down and restrict her activity. Advise the client to wait and see if her symptoms progress. Instruct the client to go to an emergency room for an urgent assessment.

Instruct the client to go to an emergency room for an urgent assessment. Explanation: The client is experiencing bright red bleeding and mucus that could be loss of her mucus plug and is often a sign of impending labor. The client needs to be seen immediately at an urgent-care medical facility. All of the other actions are not urgent enough.

An assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? feelings of relief loss of control numbness of the legs excitement

loss of control Explanation: Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

A client is in the first stage of labor. She asks the nurse what the best physical position is to promote labor progression and efficient uterine contractions. What response by the nurse is most appropriate? "Lying on your side without the use of pillows." "Lying supine will conserve energy for the second stage of labor." "The best option at this stage is to ambulate." "Any position, but ensure infrequent position changes if possible."

"The best option at this stage is to ambulate." Explanation: Standing facilitates the progression of labor because it uses the principle of gravity, and ambulation promotes both comfort and labor progression. Lying supine is not recommended unless the head of the bed is elevated to relieve the pressure of the uterus on the vena cava. Frequent position changes are recommended. Side lying is an appropriate position but body parts and joints should be well supported by pillows to relieve tension or muscle strain.

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate which other finding within the next week? The fetus will not develop gestational diabetes. The client will not develop preterm labor. The client will develop preeclampsia. The fetus will develop mature lungs.

The client will not develop preterm labor. Explanation: The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks' gestation indicates there is a less than 1% risk for developing preterm labor in the next week. Fetal fibronectin is an extracellular protein normally found in fetal membranes and deciduas, and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes.

Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation (dilatation) at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing? fear and anxiety related to the labor outcome the second stage of labor spontaneous rupture of the membranes a precipitous labor pattern

the second stage of labor Explanation: The urge to have a bowel movement, bear down, and push are all signs that the client is beginning the second stage of labor that occurs when the client is 10 cm dilated. A multigravid client generally progresses more rapidly than a primigravid client does. Therefore, it would not be unusual for a client's cervix to dilate from 5 to 10 cm or more within a 2-hour period.No evidence is presented that the client is experiencing a precipitous labor pattern, which would be evidenced by rapid cervical dilation (dilatation).No evidence is presented that the client is experiencing fear and anxiety related to the labor outcome.Spontaneous rupture of the membranes, evidenced by a sudden gush of fluid, may occur at any time in the labor process.

A nurse is caring for a gravida 1, para 0 client at 40 weeks' gestation who is in active labor. The client's cervix is 5 cm dilated and 90% effaced; the fetal station is 0, and the fetus is in cephalic presentation. The baseline fetal heart rate is 135 bpm; it decreases to 125 bpm shortly after the onset of five uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? Perform a vaginal examination to rule out umbilical cord prolapse. Position the client on their left side and administer oxygen via a face mask. Notify the health care provider (HCP) immediately, and prepare for an emergency cesarean birth. Document findings on the client's chart and continue to monitor labor progress.

Document findings on the client's chart and continue to monitor labor progress. Explanation: The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered a normal physiologic response to labor and do not require any intervention. Early decelerations do not require a position change or the administration of oxygen as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are considered to be an emergency and do not require immediate reporting to the HCP or preparing for a cesarean birth.

A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate? Inform the client and her partner that only fathers can stay in the birthing room. Ask the client if she agrees with her partner's desire to stay in the waiting room. Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. Encourage the partner to stay with the client because, as the baby's father, he is the best birth companion.

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. Explanation: This statement respects the decision of the family and facilitates open communication among the nurse, the client, and the client's partner during labor and birth.

The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? Ask the anesthesiologist to increase epidural rate. Support family members in providing comfort measures. Assist the client to push if the client feels the need to do so. Encourage the client to breathe through the urge to push.

Encourage the client to breathe through the urge to push. Explanation: The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated, and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as the nurse would like to have the client be able to push when they are fully dilated. Comfort measures are important for the client at this time, but they are not the highest priority for the nurse.

Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting longer than 90 seconds and occur every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first? Turn off the oxytocin infusion. Turn the client to their left side. Notify the health care provider (HCP). Increase the maintenance intravenous (IV) fluids.

Turn off the oxytocin infusion. Explanation: The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to their left side to better perfuse the client and fetus. Then, the nurse should increase the maintenance IV fluids to allow available oxygen to be carried to the client and fetus. When all other interventions are initiated, the nurse should notify the HCP.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan? attempting to correct any misinformation the family may have received establishing rapport with the family acting as an advocate for the family recognizing the family as active participants in their care

recognizing the family as active participants in their care Explanation: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct or correct.

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? pulmonary hypertension meconium aspiration syndrome congenital anomalies respiratory distress syndrome

respiratory distress syndrome Explanation: Respiratory distress syndrome is more common in neonates born by cesarean birth than in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth. Meconium aspiration syndrome occurs more commonly with vaginal birth, a postterm neonate, and prolonged labor, not with cesarean birth.

The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary? "I may have blood-tinged mucus when my cervix begins to efface." "Braxton Hicks contractions may stop if I walk or drink water." "I should contact my doctor if I experience a sudden gush of vaginal fluid." "I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long."

"I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long." Explanation: Although a woman having her second baby (gravida 2) may have a shorter labor than her first labor, she should still contact the healthcare provider when the contractions are every 5 minutes for at least 1 hour. Waiting until the contractions are every 2 minutes is too late. Braxton Hicks contractions do not cause cervical dilation and may stop when the client ambulates or hydrates. As a woman's cervix begins to efface, she may experience a blood-tinged mucus, known as a bloody show.

A pregnant client's labor is progressing, but the cervix is still only 5 cm dilated and 100% effaced. Although the client appears relaxed, they are aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner? "Keep a record of the contraction pattern." "Have your partner practice rapid, shallow breathing." "Suggest that your partner receive an epidural anesthetic." "Encourage your partner to rest between contractions."

"Encourage your partner to rest between contractions." Explanation: The client should be encouraged to rest as much as possible between contractions to conserve energy. In addition, the client should be encouraged to use appropriate breathing techniques, particularly slow chest breathing.Although the partner may keep track of the client's contraction pattern, this responsibility is that of the nurse caring for the client.Suggesting that the client receive an epidural anesthetic is not appropriate because the client may desire natural birth methods.Rapid, shallow breathing or pant/blow breathing is inappropriate for this stage of labor because it can cause possible hyperventilation and lead to dizziness. This type of breathing is more appropriate for the transition stage of labor.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when they say they will need to do which action? Be in a semi-Fowler position or a position of comfort. Hold their breath throughout the length of the contraction. Flex the thighs onto the abdomen before bearing down. Exert downward pressure as if having a bowel movement.

Hold their breath throughout the length of the contraction. Explanation: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing.The semi-Fowler position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired.The client should flex their thighs onto their abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter.While pushing, the client should exert downward pressure as if they were having a bowel movement.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time? Teach the client and her partner about pain transmission. Use hypnosis on the client and her partner. Instruct the partner on touch, massage, and breathing patterns. Teach the client progressive muscle relaxation.

Instruct the partner on touch, massage, and breathing patterns. Explanation: If the unprepared client has a support person, the nurse should focus on that person's supporting role, demonstrating touch, massage, and simple breathing patterns. Teaching about muscle relaxation, hypnosis, or pain transmission is inappropriate at this time because this information may make the client and her partner more anxious.

A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for which condition? uterine relaxation hyperreflexia spinal headache hypotension

hypotension Explanation: One of the most common maternal side effects after epidural anesthesia is hypotension. Therefore, the client's blood pressure must be assessed frequently after administration of this type of anesthesia. Other side effects include bladder distention, a prolonged second stage of labor, pruritus, nausea and vomiting, and delayed respiratory depression.Spinal headache may be an adverse effect of spinal anesthesia, but it is much less common with an epidural anesthetic.Hyperreflexia is not an adverse effect of epidural anesthesia.Uterine relaxation is associated with general anesthesia, not epidural anesthesia.

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. Autosomal dominant and there is a 50 per cent chance of the baby having the disease. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. X-linked dominant and there is no likelihood of the baby having cystic fibrosis.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Explanation: Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. What does this color indicate? abnormal presentation amniotic fluid embolism Rh sensitization oligohydramnios

Rh sensitization Explanation: Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid.In an abnormal presentation, in this case a breech presentation, it is not uncommon for the amniotic fluid to be green in color owing to meconium expelled by the fetus.Amniotic fluid embolism is not related to the fluid color. This condition, a medical emergency, may occur naturally after a difficult labor or from hyperstimulation of the uterus.Oligohydramnios refers to a markedly decreased volume of amniotic fluid. It has no association with the color of the fluid.

After the nurse explains the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "I'm going to have a higher blood pressure." "My contractions are going to be less painful." "My membranes are likely to have a foul odor." "I should try to push with each contraction."

"I should try to push with each contraction." Explanation: The second stage of labor begins with complete cervical dilation (dilatation) and ends with birth. During this time, the client is encouraged to push with each contraction. Throughout labor, the client's blood pressure should remain within normal limits. The membranes often rupture in the second stage of labor, but they also may rupture earlier—in some instances, even before labor begins. However, the fluid should not have a foul odor, which is indicative of an infectious process. Contractions can be strong and painful in the first stage of labor as well as the second stage.

A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? oxytocin 30 units in 500 mL dextrose 5% in water (D5W) prostaglandin gel 0.5 mg dinoprostone 10 mg misoprostol 50 mcg

oxytocin 30 units in 500 mL dextrose 5% in water (D5W) Explanation: A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicates that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft, and the presenting part is at a −1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place.

Two hours ago, a multigravid client was admitted in active labor with the cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on their lips, and extreme irritability. What should the nurse do first? Increase the rate of intravenous fluid administration. Obtain a prescription for an intramuscular antiemetic medication. Warm the temperature of the room by a few degrees. Assess the client's cervical dilation and station.

The nurse should assess the client's cervical dilation and station because the client's symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5 to 9 cm per hour during the active phase of labor. Warming the temperature of the room is not helpful because the client will soon be ready to begin expulsive pushing. Increasing the intravenous fluid rate is not warranted unless the client is experiencing dehydration. Administration of an antiemetic at this point in labor is not warranted and may result in neonatal depression should a rapid birth occur.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Discuss the case with the client's mother, who is an immediate family member. Discuss the case at lunch to educate other staff members. Use the hospital code for HIV when documenting care. Keep a unit log of all clients infected with HIV for research purposes.

Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Every facility uses a specific code to designate HIV-positive clients. To protect confidentiality, the nurse should speak about the diagnosis only with the client and any person the client designates. A nurse should never discuss a client with anyone who is not directly involved in that client's care. For instance, if the client does not give the nurse permission to speak with the client's mother, the nurse may not give the mother information about the client. Keeping a log of all HIV-positive clients violates client confidentiality.

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first? Monitor the client's contraction pattern. Assess the fetal heart rate (FHR) for 1 full minute. Assess the client's temperature and pulse. Document the color of the amniotic fluid.

Assess the fetal heart rate (FHR) for 1 full minute. Explanation: After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression or a prolapsed cord, and an FHR of 100 bpm or less should be promptly reported to the HCP. A cord prolapse requires prompt birth by cesarean. The client's contraction pattern should be monitored once labor has been established. The client's temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is present.

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first? Place gentle pressure upward on the fetal head. Turn the client on the left side. Place the cord back into the vagina to keep it moist. Begin oxygen by face mask at 8 to 10 L per minute.

Place gentle pressure upward on the fetal head. Explanation: The nurse should place a hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to their left side facilitates better perfusion to the birth parent, but until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes that increase perfusion to the infant by relieving cord compression

During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that they smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which complication? maternal hypotension placenta previa abruptio placentae ruptured uterus

abruptio placentae Explanation: Dramatic vasoconstriction occurs as a result of smoking crack cocaine. This can lead to increased respiratory and cardiac rates and hypertension. It can severely compromise placental circulation, resulting in abruptio placentae and preterm labor and birth. Infants of these women can experience intracranial hemorrhage and withdrawal symptoms of tremulousness, irritability, and rigidity. Placenta previa, a ruptured uterus, and maternal hypotension are not associated with cocaine use. Placenta previa may be associated with grand multiparity. A ruptured uterus may be associated with a large-for-gestational-age fetus.

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations from 100 to 110 bpm. What should the nurse do next? Administer oxygen via mask at 2 L per minute. Reposition the client and continue to evaluate the fetal heart rate. Notify the health care provider (HCP) of the decelerations. Perform a vaginal examination.

Reposition the client and continue to evaluate the fetal heart rate. Explanation: The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated, but the rate should be 8 to 10 L per minute. Notifying the HCP should occur if turning the client and administering oxygen does not relieve the decelerations.

Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider? Clients having assisted vaginal births are less likely to experience a postpartum hemorrhage. Using forceps will cause the neonate to develop a cephalohematoma and a vacuum extractor will not. A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Assisted vaginal births are very commonplace, especially in clients who have received epidurals.

A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Explanation: When used properly, a vacuum extractor-assisted birth causes fewer complications for the mother and the baby than a forceps-assisted birth. A cephalohematoma may occur with the use of forceps or vacuum extractors. Instruments are used during birth when individually necessary. Assisted deliveries may increase the risk for postpartum hemorrhage.

The nurse is caring for a client in labor who has tested positive for gonorrhea. Which will the nurse include in the client's plan of care? Apply an internal fetal scalp electrode. Monitor the fetal heart tones every 4 hours. Administer erythromycin eye drops to the infant after birth. Plan for a cesarean birth.

Administer erythromycin eye drops to the infant after birth. Explanation: Gonorrhea in the cervix may cause neonatal eye infection during birth as well as serious postpartum infection in the client. Although vaginal birth exposes the newborn to the gonorrhea infection, the infection is not an indication for cesarean birth. Application of an internal fetal scalp electrode would provide an open source on the fetus and expose the fetus to the infection further. Gonorrhea is not an indication to monitor the fetal heart tones more often, but because the client is in labor, fetal heart tones should be monitored more frequently than every 4 hours.

Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? Blood pressure decreases at the peak of each contraction. Alterations in cardiovascular function affect the fetus. Decreased blood pressure is the first sign of preeclampsia. Blood pressure decreases as a sign of maternal pain.

Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease.

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor. The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated.

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Explanation: The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor.

The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence? Actions were based on the advice of a more experienced nurse. The healthcare provider's (HCP's) written orders were followed. The nurse holds competencies required for nursing care. The national standards of practice were met when providing care.

The national standards of practice were met when providing care. Explanation: Following recognized standards of practice will help protect the nurse from an accusation of negligence. Nurses are responsible and accountable for their own nursing actions. Acting on the advice of a novice or experienced colleague is irresponsible and not a feasible defense for an accusation of negligence. It is expected that the nurse will have the required certifications for practice on the nursing unit. As per the scope of nursing practice, nurses are expected to follow the HCP's written orders. This does not exempt or protect the nurse from accusations of negligence.

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage? a client who is a gravida 1 para 0 at 34 weeks' gestation with mild pregnancy-induced hypertension a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy a client who is a gravida 4 para 0 with diet-controlled gestational diabetes being induced at term a client who is a gravida 2 para 1 term pregnancy with a history of genital herpes

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy Explanation: The client who has had three prior births and has polyhydramnios has the potential for uterine atony and would be most at risk for a postpartum hemorrhage. The client at 34 weeks' gestation with mild pregnancy-induced hypertension would be at minimal risk because the uterus is not extraordinarily distended at this gestation. The gravida 4 para 0 client, who has diet-controlled gestational diabetes, has a risk for hemorrhage from being induced, but their uterus should be able to contract appropriately after the birth as long as there is no history of macrosomia. A history of genital herpes is not a risk factor for a postpartum hemorrhage.

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred? abruptio placentae prolapsed cord complete uterine rupture partial placenta previa

complete uterine rupture Explanation: In complete uterine rupture, the client feels a sharp pain in the lower abdomen and contractions stop. Fetal heart rate also stops within a few minutes. In abruptio placentae, uterine instability would continue to be indicated by the fetal heart monitor tracing. With cord prolapse, contractions would continue and the client wouldn't experience pain from the prolapse itself. Although vaginal bleeding occurs with partial placenta previa, the client has no pain outside of the expected pain of contractions

A primigravida in active labor is about 10 days post-term. The client desires a pudendal block anesthetic before birth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? fundus back abdomen perineum

Contractions cease. Explanation: Tocolytics are used to stop uterine contractions. Sedation is not the purpose of tocolytics. Tocolytics have no effect on placental perfusion, the fetal pulmonary system, or lung function.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse? Instruct the client to call her physician. Instruct the client to go to an emergency room for an urgent assessment. Explain to the client that she should lie down and restrict her activity. Advise the client to wait and see if her symptoms progress.

Instruct the client to go to an emergency room for an urgent assessment. Explanation: The client is experiencing bright red bleeding and mucus that could be loss of her mucus plug and is often a sign of impending labor. The client needs to be seen immediately at an urgent-care medical facility. All of the other actions are not urgent enough.

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason? to decrease the amount of Rh-negative sensitization for the next pregnancy to destroy fetal Rh-positive cells during the next pregnancy to prevent Rh-positive sensitization with the next pregnancy to provide active antibody protection for this pregnancy

to prevent Rh-positive sensitization with the next pregnancy Explanation: The purpose of Rh immune globulin is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after the birth of an Rh-positive neonate. Clients who are Rh negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. Rh immune globulin does not cross the placenta and destroy fetal Rh-positive cells.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? use of protective goggles during a caesarean birth placement of bloody sheets in a container designated for contaminated linens disposal of used scalpel blades in a puncture-resistant container wearing of sterile gloves to bathe a neonate at 2 hours of age

wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

The health care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding? Contractions cease. The client is sedated. There is increased placental perfusion. There is improvement in fetal lung function.

"I will make every effort to work with your cultural beliefs." Explanation: The nurse knows they must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by healthcare providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.

The nurse is caring for a postpartum client with an episiotomy. The nurse assesses the client closely for what complication that the client is at greatest risk of developing? dyspareunia blood loss infection urinary incontinence

infection Explanation: An episiotomy involves cutting the perineum to accommodate the fetus, which can result in infection at the incision site. Dyspareunia (painful intercourse) may occur if infection interferes with the healing of the episiotomy site. Minimal blood loss occurs when an episiotomy is performed. Urinary incontinence is not a complication of episiotomy.

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity? the moderate amount of bloody show the intact membranes the position of the baby the frequency of the uterine contractions

the intact membranes Explanation: An FSE may not be applied with intact amniotic membranes. In order to reach the fetal scalp and apply the electrode, the membranes must be ruptured, the cervix must be dilated a minimum of 2 cm, and the presenting part must be accessible by vaginal exam. An amniotomy must be performed instead. Bloody show may be present and uterine contractions may occur regardless of whether the membranes are ruptured.

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to Women in Distress (local provincial/territorial, regional or aboriginal shelter). the social worker on call. the physician on call. a lawyer.

the social worker on call. Explanation: The social worker on call knows how to make a referral to authorities without violating the client's rights. The nurse does not need to contact the physician because the physician would also refer the client to the social worker. The nurse does not have the right to refer the client to Women in Distress, an organization that shelters victims of abuse, without the client's permission. It is not appropriate for the nurse to refer the client to a lawyer.

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response? "No, only certified registered nurses can perform this skill." "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." "Yes, but only after you read about the procedure in the regional policy and procedure manual." "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first."

"Yes, but I will demonstrate it once and then supervise you while you perform the procedure." Explanation: This method of instruction facilitates student learning by demonstration. The nurse is accountable for delegating nursing interventions to student learners. Experiential learning is an effective method of developing psychomotor tasks and critical thinking skills. EFM is not a certifiable skill specific to registered nursing practice and does not require that it be practiced in an acute care setting prior to practicing it in a community setting. It is critical that the nurse first demonstrates and then supervises the skill to ensure student learning and client safety.

A laboring client on oxytocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings which of the following would be the best action for the nurse? Increase the oxytocin until uterine contractions exceed 80 seconds duration. Continue the oxytocin until uterine contractions are more frequent than every 2-3 minutes. Discontinue the oxytocin if the uterus does not relax between uterine contractions. Administer pain medicine for reports of increasing discomfort.

Discontinue the oxytocin if the uterus does not relax between uterine contractions. Explanation: One of the nursing responsibilities with the administration of an oxytocic, such as oxytocin, is to assess for uterine hyperstimulation (as per institutional policy, i.e., Q 15 mins). Uterine hyperstimulation is defined as a uterus that does not relax between uterine contractions and/or uterine contractions that occur more frequently than 1:2, exceed 90 seconds duration, and have strong intensity. The nurse should discontinue the oxytocin. Increasing the oxytocin would endanger the client and placental blood supply to the infant. The priority is the hyperstimulated uterus; pain medicine would not be appropriate.

The nurse waits for the placenta to deliver. Which action should the nurse take? Observe for signs of placental separation. Ask the client to push down forcefully. Massage the fundus firmly. Reach into the uterus with sterile gloves.

Observe for signs of placental separation. Explanation: The best course of action is to wait for signs of placental separation, such as lengthening of the umbilical cord, a slight gush of dark blood, and a change in the contour of the fundus from discoid to globular. Pulling on the cord before the placenta is delivered may cause inversion of the uterus.After separation occurs, the client can be asked to bear down.Massaging the fundus is not helpful to ensure placental separation.Reaching into the uterus is done only when the placenta does not separate, necessitating manual removal. Doing so can lead to infection or uterine trauma.

A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin, and the interpreter is busy with an emergency situation. At the client's last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, the nurse understands that which response indicates the client may be approaching birth? The client's facial expressions become animated. The fetal monitor strip shows early decelerations. The fetal monitor strip shows late decelerations. The client begins to speak to her family in their native language.

The fetal monitor strip shows early decelerations. Explanation: When the fetal head is compressed, early decelerations are seen as a vagal response, during which the fetal heart rate decelerates and inversely mirrors the contraction. This response commonly occurs when the client is 9 cm to 10 cm dilated or pushing. If communication cannot be facilitated, early decelerations are one indicator that birth may be approaching. Late decelerations may occur at this time but indicate uteroplacental insufficiency rather than imminent birth. At any time during the labor process, the client may communicate with family in their native language. The client's facial expressions may change at any point during labor and cannot be used as an indicator of imminent birth.

The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time? methergine magnesium sulfate oxytocin terbutaline

oxytocin Explanation: An epidural can slow contractions, so many clients will need to have oxytocin to maintain contraction strength. Magnesium sulfate and terbutaline are tocolytic medications to decrease contractions, and methergine is used for postpartum hemorrhage.

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds late decelerations with minimal variability late decelerations that occur with over 50% of contractions repetitive (at least 3) uncomplicated variable decelerations

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds Explanation: An increase of 15 bpm of the FHR for the duration of at least 15 seconds is a normal, reassuring FHR pattern. Late decelerations are periodic uniform changes in the FHR that are associated with uterine contractions. Multiple late decelerations may be a result of uteroplacental insufficiency or compromised uteroplacental perfusion requiring an intervention in attempts to enhance circulation and fetal oxygenation. Repetitive variable decelerations may be associated with umbilical cord compression and may require changes in maternal positioning to relieve the cord compression.

A female client tells a nurse that they are in a same-sex relationship. The client's partner is the healthcare surrogate for the client and their fetus. The sperm donor, who is the client's close friend, has waived parental rights. If the client cannot make healthcare decisions for the fetus, who is responsible for making them? the client's parents the client's partner the sperm donor the court system, because the client is not married

the client's partner Explanation: A legal document stating that the client's partner is the healthcare surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client is not able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make healthcare decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents do not have rights to make healthcare decisions for pregnant adolescents. The court system would not make the decision if the client has designated a legal healthcare surrogate.

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict? "Clients cannot always be guaranteed there will be a female physician on call." "Your attitude toward the male physician could put the baby at risk." "I will make every effort to work with your cultural beliefs." "Please try to understand that the physician is a professional and will be escorted by a female nurse."

"I will make every effort to work with your cultural beliefs." Explanation: The nurse knows they must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by healthcare providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood? "I can expect immediate anesthesia that can be reversed very easily." "The medication will be administered while I am in the prone position." "The anesthetic may cause a severe headache, which is treatable." "My blood pressure may increase if I lie down too soon after the injection."

"The anesthetic may cause a severe headache, which is treatable." Explanation: Spinal anesthesia is used less commonly today because of the preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, and using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting or side-lying position. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time? Encourage client to drink the ice and water. Offer the client hot beverages. Increase the IV oxytocin to 125 mL/hr for hydration. Ask the client what fluids she prefers to drink.

Ask the client what fluids she prefers to drink. Explanation: Although it is common for Asian childbearing women to drink only hot beverages (birth philosophy related to yin and yang), it would be appropriate first to find out from the client what she wants to drink and determine her likes and dislikes. There is a reason she has chosen not to drink the cold beverages, so it is best to ask her what it is she does want. Increasing the oxytocin would likely increase her uterine contractions and is not appropriate practice for meeting the needs of hydration.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply. Change the client's position. Administer oxygen to the client. Contact the healthcare provider. Increase the oxytocin infusion. Discontinue the external fetal heart monitor.

Contact the healthcare provider. Administer oxygen to the client. Change the client's position. Explanation: Late decelerations are caused by placental insufficiency and need to have an active response. Increasing the oxytocin would cause the fetus to have further placental insufficiency. Discontinuing the external fetal heart monitor would be inappropriate as the fetus needs intervention. Calling the healthcare provider would be necessary for a change in the plan of care. Application of oxygen to the client would help facilitate further oxygenation of the fetus. Changing the client's position may help alleviate the decelerations if they are caused by hypotension and will help determine if the decelerations are truly late.

A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Ensure adequate hydration before the anesthetic is administered. Administer oxygen using a mask. Place the woman supine with her legs raised. Administer ephedrine to raise her blood pressure.

Ensure adequate hydration before the anesthetic is administered. Explanation: Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate? Encourage the client to inhale with as much force as possible. Give the client a paper bag and have them breathe into it. Have the client take several whiffs of oxygen through a nasal cannula. Tell the client to breathe quickly and then hold their breath.

Give the client a paper bag and have them breathe into it. Explanation: Hyperventilation results in excess carbon dioxide being eliminated from the body. Rebreathing into a paper bag or cupping the hands is beneficial because it increases the carbon dioxide remaining in the lungs during breathing.Although taking whiffs of oxygen via nasal cannula may increase oxygen intake with breathing, it will not replace the lost carbon dioxide, the major problem with hyperventilation.Having the client hold their breath has no effect on minimizing the excess carbon dioxide being eliminated. However, doing so can lead to increased intracranial pressure.Breathing with forceful inspirations will not resolve the hyperventilation nor will it replace the carbon dioxide deficiency.

The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" The client's last vaginal examination was 1 hour ago and showed the client was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? Ask the client for suggestions to make them more comfortable. Perform a vaginal examination to determine if the client is fully dilated. Help the client through contractions until a narcotic can be given. Palpate the bladder to see if it has become distended.

Perform a vaginal examination to determine if the client is fully dilated. Explanation: Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. Performing a vaginal examination would provide this answer. The use of narcotic medications is discouraged at this stage as they can lead to respiratory depression in the neonate. Palpating the bladder is an important intervention, but it is not the highest priority as it was done less than an hour ago. Since the nurse has correctly completed the most logical steps, asking for the client's input would certainly be in order but not the highest priority intervention.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Cover the cord with sterile towels. Administer oxytocin intravenously. Ask the client to begin pushing. Place the client in the Trendelenburg position.

Place the client in the Trendelenburg position. Explanation: The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client's head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the umbilical cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean birth is usually performed.Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus.Pushing results in further cord compression and decreased fetal heart rate.With umbilical cord prolapse, an immediate cesarean birth is indicated. There is no need to cover the cord to avoid damage or tearing.

A client at 28 weeks' gestation is admitted in preterm labor. An IV infusion loading dose of 4 g magnesium sulfate is started IV piggyback at a rate of 300 mL/min. After 15 minutes, the nurse assesses the client's deep tendon reflexes and finds them hyporeflexive. What is the nurse's priority intervention? Call the health care provider. Check the client's blood pressure. Stop the magnesium sulfate infusion. Give calcium gluconate IV push.

Stop the magnesium sulfate infusion. Explanation: Magnesium sulfate is a central nervous system (CNS) depressant that relaxes smooth muscles including the uterus. Adverse effects include decreased respiratory rate, decrease in deep tendon reflexes (hyporeflexia), hypotension, decreased urine output, pulmonary edema, and headache. The priority intervention would be to stop the infusion, assess the client's vital signs, then call the provider to report the client's status and obtain a prescription for a magnesium level. Calcium gluconate is the antidote and would be given in case of severe respiratory depression. Complications from the administration of magnesium sulfate include magnesium toxicity, which is evidenced by cardiac and CNS depression. Toxicity is rare in women with good kidney function. At serum magnesium concentrations of 4 mEq/L to 6 mEq/L (2 mmol/L to 3 mmol/L), flushing, sweating, nausea, headache, drowsiness, lethargy, and decreased deep tendon reflexes may occur. At 6 mEq/L to 10 mEq/L (3 mmol/L to 5 mmol/L), somnolence, hypocalcemia, absent deep tendon reflexes, hypotension, bradycardia, and electrocardiogram changes may occur. Other signs and symptoms of magnesium toxicity include a respiratory rate of fewer than 16 breaths/minute, an oxygen saturation level of less than 95%, slurred speech, and chest pain. Weakness and decreased urinary output are other potential adverse effects of magnesium sulfate administration. At magnesium levels of greater than 10 mEq/L, muscle paralysis, flaccid quadriplegia, apnea, respiratory failure, complete heart block, and cardiac arrest are likely.

The primary health care provider prescribes whole blood replacement for a multigravid client with abruptio placentae. What should the nurse do first before administering the intravenous blood product? Ask the client if they have ever had any allergies. Check the vital signs before transfusing over 5 to 6 hours. Validate client information and the blood product with another nurse. Administer 100 ml of 5% dextrose solution intravenously.

Validate client information and the blood product with another nurse. Explanation: When administering blood replacement therapy, extreme caution is needed. Before administering any blood product, the nurse should validate the client's information and the blood product with another nurse to prevent the administration of the wrong blood transfusion. Although baseline vital signs are necessary, the nurse should initiate the infusion of blood slowly for the first 10 to 15 minutes. Then, if there is no evidence of a reaction, the nurse should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if they have ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administration. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions.

The nurse is managing the care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? anesthesia and pain level assessment every 30 minutes vaginal bleeding, rupture of membrane assessment every shift oxygen saturation monitoring every half hour supine positioning on the back, if it is comfortable

anesthesia and pain level assessment every 30 minutes Explanation: The nurse should monitor anesthesia and pain levels every 30 minutes during active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client. When in active labor, oxygen saturation is not monitored unless there is a specific need, such as heart disease. The client should not be on their back but wedged to the right or left side to take the pressure off the vena cava. When lying on the back, the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 minutes to 1 hour.

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? assessing the neonate for respirations placing antibiotic ointment in the neonate's eyes turning the neonate's head to the side to drain secretions checking for the umbilical cord around the neonate's neck

checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. The client has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, they receive nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor? effects of analgesic medication fetal malposition maternal fatigue small-for-gestational-age fetus

effects of analgesic medication Explanation: Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhythmias. Maternal fatigue, fetal malposition, and a small-for-gestational-age fetus are not commonly associated with decreased variability.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if any of the clients have which finding? sleeping after administration of intravenous (IV) nalbuphine an episode of nausea after administration of an epidural anesthetic contractions 3 minutes apart and lasting 40 seconds evidence of spontaneous rupture of the membranes

evidence of spontaneous rupture of the membranes Explanation: The nurse expects the UAP assigned to several clients in labor to notify the nurse if the UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the membranes rupture spontaneously, there is the danger of a prolapsed cord, a medical emergency requiring a cesarean birth.Nausea may occur after administration of an epidural anesthetic, but this is not a priority or emergency.Having contractions that are 3 minutes apart and lasting for 40 seconds is normal during active labor.Because nalbuphine is an analgesic medication, it is normal for a client to fall asleep after IV administration of this drug.

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important? maternal pulse fetal heart rate level of consciousness level of anesthesia

fetal heart rate Explanation: The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. While measuring maternal pulse is important, this vital sign does not tell the nurse as much about fetal perfusion as the fetal heart rate or maternal blood pressure. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy.The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia.Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, though important for any client, is not the priority following epidural anesthesia

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose? assessment of the fetal hematocrit level increase in the strength of the contractions assessment of fetal position increase in the fetal heart rate and variability

increase in the fetal heart rate and variability Explanation: Fetal scalp stimulation is commonly prescribed when there is decreased fetal heart rate variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the fetal heart rate and variability. However, if the fetus is in distress and becoming acidotic, fetal heart rate acceleration will not occur. The fetal hematocrit level can be measured by fetal blood sampling. Scalp stimulation does not increase the strength of the contractions. However, it can increase fetal heart rate and variability. Fetal position is assessed by identifying skull landmarks (sutures) during a vaginal examination.

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position? transverse posterior breech anterior

posterior Explanation: When a client has severe back pain during labor, the fetus is most likely in an occiput posterior position. This means that the fetal head presses against the client's sacrum, causing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known before 8-cm dilation, and a cesarean birth is performed. A fetal occiput anterior position does not increase the pain felt during labor.

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean birth. The client tells the nurse that they have been taking gingko biloba to help manage blood sugar. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication? medication interactions prolonged bleeding oversedation hypertensive crisis

prolonged bleeding Explanation: Ginkgo biloba is an herbal supplement commonly taken to improve memory or improve glycemic control. It has known antiplatelet effects and can put surgical clients at risk for bleeding. It is not known to cause hypertension or sedation. Ginkgo biloba's primary medication interaction relates to its potential to enhance the effects of other anticoagulants and lead to prolonged bleeding.