Maternal Newborn - Intrapartum Care
A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing?
Contractions that last for 60 sec each with a 3 min rest between contractions Rationale: A contraction interval indicates how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 minutes is equivalent to contractions every 4 minutes.
A nurse is monitoring a laboring client and has applied a fetal heart monitor. She notes that the fetal heart rate is 170 bpm with beat-to-beat variability. Which of the following describes the most likely tracing observed by the nurse?
Fetal tachycardia Rationale: When measured by electronic fetal monitoring, a normal fetal heart rate (FHR) is between 110 and 160 bpm. A rate of more than 160-180 beats per minute (bpm) represents fetal tachycardia. Fetal tachycardia usually ranges between 170-220 bpm. Nonreassuring patterns include fetal tachycardia, bradycardia, and late decelerations with good short-term variability. Nonreassuring patterns should be evaluated further to rule out fetal acidosis.
A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first?
Place the client in a side-lying position Rationale: According to evidence-based practice, the nurse should act quickly to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord. Other interventions: - The nurse should perform or assist with a vaginal examination to check for umbilical cord prolapse because this can cause variable decelerations - The nurse should discontinue the oxytocin infusion because fetal distress must resolve before proceeding with the birth - The nurse should administer oxygen to help prevent or relieve fetal hypoxia
A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?
Offer the client hydrotherapy Rationale: Therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. Therapeutic rest can include hydrotherapy and analgesia to relieve pain. Decreasing uterine contractions and helping the client relax and sleep will help prevent early exhaustion.
A nurse is teaching a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include?
"You will learn how to prevent pain during labor by focusing your mind to control your breathing." Rationale: The Lamaze philosophy is based on prophylaxis by using the mind. The method is based on the theory that through stimulus-response conditioning, clients can learn to use controlled breathing to reduce pain during labor. Other considerations: "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions." This response is representative of the Dick-Read method of managing pain during childbirth because it focuses on reducing fear. Fear is reduced through education prior to labor. "During labor, you will be encouraged to disassociate by using an internal focal point." This response is representative of the Bradley or partner-coached method. This method is based on the premise that pregnancy and childbirth are joyful, natural processes and that a woman's partner should play an active role during pregnancy, labor, and the early newborn period. During labor, you will use conscious relaxation and levels of progressive breathing." The psychosexual method includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to flow with rather than struggle against contractions.
A nurse is caring for a client in the labor and delivery service who is receiving oxytocin after prolonged labor. Intervention is necessary when which assessment finding is noted?
6 contractions in 10 minutes Rationale: Uterine tachysystole is characterized by more than 5 contractions in 10 minutes averaged over a 30-minute time period, a series of single contractions lasting longer than 2 minutes, or contractions of normal duration that occur within a minute of each other. Initial nursing interventions, if the fetal heart rate tracing is reassuring, include repositioning the client in the side-lying position, administration of an IV fluid bolus, and reduction or discontinuation of oxytocin. If the FHR tracing is non-reassuring, with fetal bradycardia, late decelerations, or decreased variability with tachycardia, the nurse should stop the oxytocin infusion immediately and reposition the client. Oxygen can be given at 10 L/minute by face mask if abnormalities do not improve. An IV fluid bolus can be given, and the healthcare provider should be notified. Terbutaline may be prescribed per protocol or by the HCP to treat the client. Oxytocin, a hormone produced in the posterior pituitary gland, stimulates uterine contractions and let-down of milk. A synthetic form, Pitocin, is used to induce or augment labor and to control postpartum bleeding. It is associated with potential risks of uterine tachysystole, postpartum hemorrhage, infection, and death from water intoxication, as well as uterine rupture, placental abruption, and unnecessary cesarean birth as a result of abnormalities in fetal heart rate patterns.
A nurse is caring for a client who is in labor and is delivering her baby. Which of the following statements regarding amniotic fluid embolus are true? (Select all that apply.)
Amniotic fluid embolus occurs when a foreign object or substance enters the mother's circulation The signs and symptoms of an amniotic fluid embolus are similar to those of anaphylactic shock Rationale: An amniotic fluid embolism is a life-threatening complication that typically occurs during the time of labor or within the first few hours after delivery; signs and symptoms involve breathing difficulties and are often similar to those of anaphylactic shock. The condition develops when an embolus, or clot, travels through the bloodstream to lodge in a major vessel and prevent blood flow to an organ, such as the brain, the heart, or the lungs. Amniotic fluid embolism is characterized by sudden dyspnea, chest pain, tachycardia, hypotension, and a bluish-gray complexion that is also seen in clients with a pulmonary thromboembolism. Death may occur within minutes without rapid intervention. Treatment of amniotic fluid embolism is supportive and includes administration of oxygen to maintain normal saturation; fluid resuscitation and pressors; and initiation of cardiopulmonary resuscitation (CPR) if the patient arrests.
A nurse is caring for a multigravida client in the process of delivery. The fetal head meets resistance as it descends along the soft tissues of the pelvis, muscles of the pelvic floor, and cervix. What intervention does the nurse anticipate?
Assist the obstetrician to proceed with vaginal delivery Rationale: The fetus undergoes positional changes in order to pass through the vaginal canal. These positional changes are called cardinal movements, and they are composed of: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. When the fetal head descends, it meets resistance from the soft tissue of the pelvis, muscles of the pelvic floor, and cervix. In order to pass through the resistance, the fetal chin flexes downward onto the chest. This is known as flexion. It is best to proceed with the delivery as this is one of the cardinal movements. Assisting the obstetrician for emergency cesarean section, administering prescribed medication to relax the uterus, and repositioning the client on her side are not necessary unless indicated due to cephalopelvic disproportion or other risks for both mother and fetuss.
A nurse is preparing to set up continuous internal fetal monitoring for a high-risk pregnant client who is in labor. Which of the following must be present before the nurse initiates internal fetal monitoring?
Cervical dilation of at least 2 cm Rationale: Continuous internal fetal monitoring is a useful tool for consistently assessing fetal heart rate during labor for high-risk clients. When setting up an internal fetal monitoring system, a probe that measures the heart rate is inserted into the baby's presenting part, which is usually the scalp if it is a cephalic presentation. The mother must have a cervical dilation of at least 2 cm before the probe can be internally placed. Fetal heart rate monitoring during labor demonstrates changes in fetal heart rate patterns in response to contractions. Auscultation, internal monitoring, or external fetal monitoring can be utilized. Auscultation can be performed using a Doppler transducer. External monitoring is performed by wrapping a pair of belts around the mother's abdomen. One belt uses Doppler to detect the fetal heart rate while the other belt measures the length and timing of contractions. Internal monitoring is performed using an electrode that is placed on the presenting part of the fetus, usually the scalp, to record the fetal heart rate. Uterine contractions may be monitored using an intrauterine pressure catheter inserted through the vagina. Internal monitoring can be used only after the membranes have ruptured
Which of the following responses would the nurse expect to see from a client who is in the latent phase of labor?
Contractions every 5 to 10 minutes. Rationale: The latent phase occurs during the first stage of labor when a woman's body is beginning to change for childbirth. During the latent stage, the nurse can expect to see contractions that are still several minutes apart and that last for 30 to 40 seconds. Cervical dilation is between 0 and 3 cm during the latent phase and effacement ranges from 0 to 40 percent. Vital Concept: Labor begins when the mother feels regular contractions, which result in cervical dilation and effacement. Effacement refers to softening and thinning of the cervix, which allows the baby to enter the birth canal. The stages of labor include early or latent labor, which lasts until the cervix has dilated to 3 cm; the active phase, which lasts from the time the cervix is dilated 3 cm until the cervix has dilated to 7 cm; and the transition phase, which lasts from cervical dilation of 7 cm until the cervix has dilated to 10 cm. The first stage of labor is the longest stage, with an unpredictable length ranging from hours to days.
A nurse is caring for a client who is in active labor. Which of the following interventions should the nurse perform after examining the fetal monitoring strip shown below? (Select all that apply.) The strip shows late decelerations with minimal variability. Persistently minimal or absent fetal heart rate variability is a significant indicator of fetal compromise.
Discontinue oxytocin if oxytocin is being administered Run the IV fluids at a wide open rat Rationale: The nurse would run the IV fluids wide open, turn the client on her left side, and decrease rate of oxytocin (Pitocin) infusion, if Pitocin is being administered. During labor, the fetal oxygen supply may be compromised by a number of different mechanisms. Maternal hypotension can occur when the mother is in the supine position; in cases of hemorrhage or hypovolemia; and as a result of vasodilation caused by epidural analgesics or anesthetic agents. During uterine contraction, there may be transient compression of the umbilical cord, resulting in compromise of the fetal blood supply. Oxytocin administration can result in a hypertonic uterus and subsequent reduction of blood flow to the placenta. Fetal heart rate monitoring demonstrates the response of the fetal heart rate to maternal contractions, which affect the fetal oxygen supply during labor Late decelerations refer to a decrease of the fetal heart rate, with the lowest point of deceleration occurirng after the peak of contraction. The heart rate then returns to baseline after the contraction ends. Late decelerations indicate uteroplacental insufficiency and fetal distress.
A nurse is planning to administer terbutaline to a client who is in premature labor. The nurse should closely monitor the client and notify the provider if the client experiences which of the following adverse effects?
Dyspnea Rationale: The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially life-threatening complication of terbutaline. This adverse effect should be reported to the provider immediately. Headaches, Anxiety, Tremors, or shakiness; are a common, non-life-threatening adverse effect related to terbutaline therapy. Terbutaline is a beta-adrenergic agonist that is most often administered for tocolysis. Tocolysis is an obstetrical procedure carried out with the use of medications with the purpose of delaying the delivery of a fetus in women presenting preterm contractions. The medication is administered subcutaneously while another medication with a slower onset of action is administered concurrently. Also, a subcutaneous injection of 0.25 mg can be given during labor augmentation or induction to suppress uterine tachysystole or to suppress contractions before cesarean birth.
A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take?
Encourage the client to frequently change positions. Rationale: During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the second stage of labor. The client should remain on bedrest during this stage of labor due to impending delivery.
Into which of the following positions should the nurse assist a client to facilitate progress in labor when the fetus is in the occiput posterior position?
Hands and knees Rationale: The occiput posterior position refers to the position of the baby with head down and back to the side. This is the most common type of malposition of the occiput during labor. The nurse should assist the client to a position on the hands and knees to facilitate rotation of the fetus from the posterior to the anterior position. The occiput posterior position occurs as a result of failure of internal rotation before delivery, causing the occiput to lie in the posterior portion of the pelvis, instead of the anterior pelvis, with the vertex presenting. This causes the head to be deflexed. In most cases, the occiput rotates anteriorly when the occiput meets the pelvic floor, allowing normal delivery. Assisting the client to a position on the hands and knees may facilitate rotation to the anterior position.
A nurse is assessing a client who is in labor and received an epidural anesthesia block for pain relief. Which of the following manifestations should the nurse identify as an adverse effect of the epidural block?
Hypotension Rationale: The nurse should identify hypotension as an adverse effect of epidural anesthesia. To minimize the likelihood of hypotension, the nurse should administer an IV fluid bolus prior to the placement of the epidural catheter. Nursing Interventions for maternal hypotension • Increase IV infusion rate. • Administer oxygen by nonrebreather mask at 10 L/min. • Elevate the client's legs. • Place client in a lateral position. • Monitor BP and FHR every 5 min. • Remain with the client until condition improves.
A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take?
Maintain the client in a side-lying position for 30 min after insertion Rationale: The client should maintain a side-lying or supine position with a lateral tilt for 30 to 40 minutes after the insertion of the medication to allow the gel to stay in contact with the cervix. Using a warm-water bath or microwave to accelerate the warming of the gel can inactivate the ingredients. The gel should be allowed to thaw at room temperature. Fetal heart rate and contractions should be assessed continuously because prostaglandin E2 gel can cause tachysystole and fetal distress. Initiation of an oxytocin infusion should be delayed for 6 to 12 hours after the last instillation of prostaglandin E2 gel.
A nurse is caring for a client who is planning a vaginal birth after cesarean section (VBAC). Which of the following findings on the assessment of the client is a priority for intervention by the nurse (select all that apply). One, all, or some of the answer options may be correct)?
Maternal tachycardia Cessation of contractions Rationale: Maternal hemodynamic instability is characterized by hypotension and tachycardia. Vaginal birth after cesarean section can result in increased risk of uterine rupture as a result of weakening of the uterus along the previous surgical scar. Uterine rupture is initially characterized by constant abdominal pain, abnormal fetal heart rate patterns (bradycardia is most common), cessation of uterine contractions, and loss of fetal station. This is a life-threatening emergency for mother and fetus. Clients who are planning VBAC should not undergo induction; after spontaneous onset of labor, they should be monitored closely throughout the intrapartum and postpartum periods. Caesarean delivery is indicated after stabilization with intravenous fluids. A hysterectomy is often necessary. Fetal tachycardia with moderate variability, Increased discomfort with contractions; during active labor, contractions may occur every 2 minutes, are expected in the setting of progression of labor and delivery. Uterine rupture is a concern in clients in labor who have predisposing conditions, including a history of previous caesarean section of other type of uterine incision. Complete uterine rupture is characterized by tearing of the peritoneum. Emergent laparotomy, with C-section and hysterectomy usually necessary to prevent maternal/fetal mortality.
A nurse is caring for a client at term gestation who is in labor and anticipating simple vaginal delivery. Which of the following is an example of a warning sign of potential complications? (Select all that apply.)
Meconium-stained amniotic fluid Foul-smelling vaginal discharge Rationale: Foul-smelling vaginal discharge indicates the presence of infection, which could cause complications for both the mother and the fetus. Meconium-stained amniotic fluid is a warning sign. Meconium is the first stool of an infant, composed of materials ingested during the time the infant spends in the uterus, and usually stored in the fetal intestines until after birth. Meconium (stool) is sometimes released into the amniotic fluid during labor in response to fetal distress. If the infant inhales the contaminated fluid, meconium aspiration syndrome may occur. Other considerations: Excessive bleeding could occur for several reasons, including perineal laceration or placental abruption. Excessive bleeding that is severe enough to cause low blood pressure can indicate a significant problem that puts the mother and fetus in danger. A warning sign of complications might occur if the mother had a fever. A normal fetal heart rate is between 110 and 160 bpm Moderate fetal heart rate variability on fetal heart monitoring is normal.
A nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. Which of the following findings should the nurse identify as the priority?
Nonreactive nonstress test Rationale: The priority finding is a nonreactive nonstress test. A nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign when the FHR increases by 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. An absence of FHR accelerations suggests that the fetus might be going into distress. Monitor closely: Pre-eclampsia is the development of edema, elevated blood pressure, and proteinuria during pregnancy.. 1+ proteinuria should be closely monitored. Pre-eclampsia involves a blood pressure reading of 140/90 mmHg or greater and an increase of 30 mmHg or more in systolic pressure or 15 mmHg in diastolic over baseline on 2 occasions taken at least 6 hours apart. The fundal height should be approximately the same as the number of weeks of gestation, plus or minus 2 cm.
A nurse is caring for a G1P0 client who has been in the latent phase of labor for 21 hours. Her healthcare provider plans an amniotomy followed by oxytocin administration. Which of the following nursing interventions will be necessary (select all that apply)?
Note the amniotic fluid characteristics Assess the fetal heart rate before and after the amniotomy Rationale: The latent phase of labor occurs before the cervix has dilated to 6 cm. It is considered prolonged at 20 hours or more in a primigravida and at 14 hours or more in a multigravida. Interventions include administration of oxytocin and performance of an amniotomy, which is a procedure that ruptures the amniotic membrane in order to initiate labor or to augment prolonged labor. After this procedure, umbilical cord prolapse may occur if the fetal head is not firmly applied to the cervix. This can result in fetal hypoxemia and distress. The fetal heart rate should be assessed before and after the procedure for variable or late decelerations. The nurse should also anticipate assessment of the amniotic fluid color, odor, and amount. It should be clear, without a foul or strong odor, and colorless. Passage of yellow- or green-stained amniotic fluid indicates the fetus has passed meconium in utero. A foul odor may indicate infection. After rupture of membranes, the risk of infection is increased in the mother. The client's temperature should be monitored at least every 2 hours after artificial rupture of membranes by amniotomy. Although there may be pressure and discomfort, the procedure does not cause pain. The client should be assisted to an upright position after the amniotomy in order to allow the drainage of amniotic fluid and to facilitate positioning of the fetal head in a position firmly against the cervix. The supine position diminishes the uteroplacental flow of blood and subsequently diminishes fetal oxygenation.
A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include?
Palpate and count the maternal radial pulse while listening to the fetal heart rate Rationale: The nurse should palpate and count the maternal pulse while listening to the fetal heart rate to validate findings and distinguish the maternal pulse from the fetal heart. When assessing fetal wellbeing with intermittent auscultation, the nurse will establish the baseline fetal heart rate by counting for 30 to 60 seconds after each contraction. This will identify any discrepancies in the baseline of the fetal heart rate. The listening device should be placed over the fetal back to hear the fetal heart rate. This area has the clearest and loudest sounds. The nurse should palpate the abdomen to verify the position of the fetus.
An anesthesiologist is providing pain medication for a client who is in labor. He injects medication that provides a local anesthetic for pain relief to the vulva, the perineum, and the lower aspect of the vagina. Which of the following best describes this type of pain control?
Pudendal nerve block Rationale: A pudendal nerve block can be used during labor to anesthetize the nerves that send pain messages from the vagina and perineum. This type of block involves the injection of medication into the pudendal nerves (S2-4), which pass near each ischial spine. A pudendal nerve block may be an option for pain control if a client needs an assisted delivery, such as with the use of forceps or an episiotomy. Other anesthetic procedure: Intrathecal anesthesia involves placing anesthetic medication into the fluid surrounding the spinal cord. The intrathecal administration method causes numbness in the lower part of the body, not just in the area surrounding the vulva and perineum. A Patient-controlled epidural is a regional nerve block that provides loss of sensation below the T8-T10 spinal level and involves injecting medication into the epidural space in the spine. The medication may be delivered at a continuous rate and the client may be able to control a bolus of medication to be given. Other analgesic/anesthetics used during labor include spinal analgesia, combination spinal and epidural analgesia, and general anesthesia.
A nurse is assessing a pregnant client who states she is in labor but has not received prenatal care. The nurse attempts to identify how quickly her labor is progressing. Which of the following client behaviors indicates that birth is imminent?
Sitting on one buttock Rationale: There are several behaviors that a pregnant client may exhibit that indicate that labor is imminent, including sitting on one buttock, making grunting sounds, bearing down during contractions, or making outright statements like "the baby is coming now." Pain in the lower back is not necessarily a sign of imminent birth. The client would more likely have pain or pressure in the vagina, which indicates that delivery is about to happen. The progression of labor is divided into three phases. When a client arrives at a healthcare facility in labor, the nurse must gather pertinent information about the client's health history, including blood type, allergies, previous illness, pregnancy complications, preferences for labor and delivery, childbirth preparations; and obstetric, medical, and social history. In addition to an assessment of the client's behaviors, the nurse assesses vital signs, physical exam, contraction pattern (frequency, interval, duration, and intensity), fetal well-being (through assessment of fetal heart rate); rupture of membranes, characteristics of amniotic fluid, and contractions. The nurse should perform Leopold's maneuver to determine the fetal presenting part, point of maximum impulse, fetal descent and engagement.
A nurse is caring for a client who has received epidural anesthesia during labor. Immediately after the epidural is administered, the nurse notes decreased beat to beat variability and late decelerations on the fetal heart monitor. Which of the following interventions should the nurse implement? (Select all that apply.)
Turn client on left side Increase IV fluid rate Rationale: Maternal supine hypotension is caused by the weight of the gravid uterus on the ascending vena cava. This decreases the venous return to the woman's heart and results in decreased cardiac output and a decrease in blood pressure which in turn causes fetal distress from decreased oxygen in the blood. There is no pressure on the vena cava when the mother is on her side. After an epidural there usually is a decrease in the maternal blood pressure from systemic vasodilation. A decrease in maternal blood pressure corresponds to a decrease in blood supply to the fetus, causing fetal distress. An IV fluid bolus aids in maintaining the blood pressure at or near pre-epidural levels. Regional analgesia by epidural or spinal provides partial or complete loss of pain sensation below the T8 to T10 spinal level. Some degree of motor block may be present, depending on the medication used. Advantages of regional analgesia include the ability to avoid opioids for analgesia, which can depress maternal and fetal respiration; better pain relief in the first and second stages of labor; provides anesthesia for an episiotomy, if that is necessary; and anesthesia can be extended for cesarean delivery.
A nurse is preparing to administer oxytocin to a client to stimulate uterine contractions. Which of the following actions should the nurse plan to take? (Select all that apply.)
Use an infusion pump for medication administration. Monitor maternal blood pressure and pulse frequently. Monitor the fetal heart rate continuously. Rationale: The nurse should plan to administer oxytocin using an infusion pump to ensure precise flow rate. The nurse should plan to monitor the client's blood pressure and pulse rate to assess for hypertension, which is an adverse effect of oxytocin. The nurse should plan to monitor the fetal heart rate continuously to assess for fetal distress. Oxytocin is a peptide hormone produced by the posterior pituitary. Indications for oxytocin are: • Induction or stimulation of labor • Postpartum hemorrhage • Incomplete/inevitable abortion Nursing implications include: • Assessment of character and frequency and duration of uterine contractions - Oxytocin therapy should not be interrupted unless contractions persist for more than 1 min or occur more often than 2 to 3 min. • Frequent monitoring of maternal blood pressure and pulse rate • Continuous monitoring of fetal heart rate • Observe for signs and symptoms of water intoxication, including drowsiness, confusion, headache, and anuria • Monitor maternal electrolytes, especially for hyponatremia or hypochloremia - increase the oxytocin flow rate gradually to prevent hypertonic uterine contractions.
A nurse on a labor and delivery unit is caring for a client who is at 38.3 weeks of gestation. The client reports that uterine contractions started 2 hr ago, are occurring every 5 to 10 min, and last 60 seconds. Which of the following findings indicates the client is experiencing true labor?
Vaginal exam reveals that the cervix is 5 cm dilated, 80% effaced, and soft. rationale: Clients are admitted to the labor and delivery unit when they show findings of active labor. Labor findings include cervical dilation of 4 to 5 cm, cervical effacement of greater than or equal to 80%, and contractions occurring at regular intervals that are increasing in frequency, intensity, and duration. Other considerations: - A fetal station of +1 is not an indication of true labor. The presenting part can be below the level of the ischial spines before the onset of labor. - Vertex presentation is the most common and desirable fetal presentation for childbirth, but the fetal presentation does not determine if a client is in true labor. - The status of the amniotic membrane does not determine labor or its progression. The amniotic membrane can spontaneously rupture before labor or during labor, or the provider may artificially rupture the membrane.
While caring for a client who is in labor, the nurse performs a vaginal exam. During the exam, she notes on the monitor that the baby's heart rate jumps from 110 bpm to 140 bpm. Based on knowledge of fetal heart rate monitoring, which of the following actions by the nurse is most appropriate?
Continue to monitor FHR but make no changes Rationale: An increase in FHR from 110 bpm to 140 bpm is most likely in response to stimulation from the vaginal exam. The fetal heart rate is not outside of normal parameters. The nurse should note the change and continue to monitor. Fetal distress is reflected by changes in the normal pattern of fetal heart rate in response to uterine contractions during labor.
A nurse is caring for a client who is in labor with cervical dilation of 5 cm. Which of the following findings on the assessment requires intervention by the nurse?
Duration of contractions of 100 seconds Rationale: Normal uterine contractions in the active phase of the first stage of labor (which begins at some point when the cervix is dilated between 4-7 cm) should not last longer than 90 seconds. Typically, the length of uterine contraction is 40-70 seconds. Other considerations: The first stage of labor is characterized by 2-5 contractions every 10 minutes. Contractions should occur no more frequently than once every 2 minutes. More frequent contractions can result in uteroplacental insufficiency. Resting tone refers to the tension in the uterine muscles between contractions. The tension averages 10 mmHg and should not exceed 20 mmHg in order to allow perfusion of the placenta and fetal oxygenation between contractions. The intensity of contractions refers to the strength of contractions at the peak and should not exceed 80 mmHg. Contraction intensity during the first stage of labor generally ranges from 25-50 mmHg. Uterine hypertonicity is characterized by intrauterine pressure >80 mmHg.
A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect?
Prolapsed umbilical cord Rationale: The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately. Other signs: Signs of uterine rupture include constant abdominal pain, loss of fetal station, abnormal fetal heart rate tracing, and cessation of contractions. Manifestations of placenta abruption include abdominal pain, vaginal bleeding, uterine tenderness, and contractions. Signs of amniotic fluid embolus include maternal respiratory distress, and hemodynamic instability.
A nurse is caring for a client who is in labor. The fetal monitor shows bradycardia. Which of the following can result in fetal bradycardia?
The mother has received spinal anesthesia. Rationale: The administration of spinal anesthetic medications to the mother causes maternal hypotension that results in fetal hypoxia, a cause of fetal bradycardia. The most common causes of fetal bradycardia in the intrapartum period include poor uterine perfusion, maternal hypotension after spinal anesthesia, umbilical cord prolapse, rapid fetal descent, tachysystole, placental abruption, or uterine rupture. Other considerations: A vaginal exam may be more likely to stimulate the fetus and cause an increase in the heart rate. Chorioamnionitis would more likely cause an increased fetal heart rate in response to infection. Maternal dehydration may cause a decrease in overall circulating fluid and an increased fetal heart rate as a compensatory response.
A nurse is caring for a client who is in active labor and just had an amniotomy performed by the provider. Which of the following findings indicates a need for further evaluation? Select all that apply.
- Amniotic fluid is stained with meconium. Meconium-stained amniotic fluid can indicate fetal distress. - Minimal FHR variability. Minimal or absent variability can indicate fetal metabolic acidemia or hypoxemia at the time it is observed. - An abrupt decrease in the FHR below the baseline. This finding indicates a variable deceleration, which is a manifestation of cord compression.
A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern?
Contractions lasting 100 seconds Rationale: Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds. Contraction frequency ranges from 2 to 5 contractions per 10 minutes during labor. Contractions occurring every 4 to 5 minutes are within the expected range. Pink, mucoid vaginal discharge describes the bloody show, an expected finding during labor.
A nurse is caring for a client with pregnancy-induced hypertension who is scheduled for a cesarean section. In which position should the nurse place the client before she is transferred to the delivery suite?
Left lateral Rationale: Positioning client on her left side will take the pressure off the inferior vena cava and will increase blood return to the heart. Pregnancy induced hypertension causes impaired blood flow to the fetus. Bedrest in the left lateral recumbent position can increase fetal blood flow, since the uterus is moved away from the maternal inferior vena cava and the right iliac artery. This causes spontaneous diuresis due to increased blood flow to the kidneys and increases blood flow to the heart, increasing the clients cardiac output.
A nurse is caring for a client who is in labor and has HIV. Which of the following procedures should the nurse identify as being safe for this client? (Select all that apply.)
Oxytocin infusion Cesarean birth Rationale: Oxytocin infusion is a noninvasive procedure that is considered safe for this client because there is little risk for maternal blood exposure to the fetus. Cesarean birth can be recommended for clients who have HIV, depending on their viral load, to reduce the risk for transmission of HIV to the fetus. Clients who are pregnant and have HIV should have a scheduled cesarean section at 38 weeks of gestation to decrease the risk for transmission of the virus to the fetus. The client should be given increased loads of viral medications prior to and during the scheduled cesarean section. Vaginal delivery is only recommended for those clients with a viral load of fewer than 1,000 copies/mL. Invasive procedures or procedures that could cause maternal blood exposure to the fetus are not recommended. Procedures such as episiotomies, vacuum deliveries, the use of forceps, and internal fetal monitoring should be avoided because they are considered invasive and could result in exposing the fetus to maternal blood.
Describe the stages of Childbirth (labor) Stage 1: Dilation Stage 2: Birth: Stage 3: Afterbirth Stage 4: Recovery.
Stage 1: Dilation The phases of the first stage of labor are early labor (latent), active labor, and transition. In early labor, the cervix dilates from 1 to 4 cm and thins out. Contractions occur every 5 to 30 minutes and are 30-45 seconds in length. In active labor, the cervix dilates to 4 to 7 cm and thins further. Cervical dilation is usually 1 cm per hour. Contractions are noticeably stronger and longer (45 to 60 seconds) every 3 to 5 minutes. Active labor lasts about 4 to 8 hours. Cervix dilates to 8 to 10 cm and thins. Transition is the shortest phase, but it is the most intense and painful phase, lasting on average 30 minutes to 2 hours and longer for first time mothers. Contractions are very intense and back to back, lasting 60-90 seconds and occurring every 2-3 minutes. Stage 2: Birth: Stage 2 of labor begins when the cervix is fully dilated and ends when the baby is delivered. When the cervix is fully dilated, the baby starts to descend into the birth canal. Contractions will be strong and intense, as in the transition period. Stage 3: Afterbirth The fetus is delivered and ends when the placenta detaches and exits vagina. Stage 4: Recovery.
The nurse is caring for a client in the fourth stage of labor immediately following the successful vaginal delivery of a healthy baby girl. Identify the .risk factors predisposing this client to postpartum hemorrhage (PPH).
- G6 T5 P0 A0 L5 - Gestational hypertension - Prolonged labor - Oxytocin (Pitocin) was started to facilitate dilation and cervical progress. - The client delivered vaginally with vacuum assistance. - 9 lb 15 oz (4500 g) Rationale: When analyzing the cues in a client's chart following labor and delivery, the nurse must recognize the risk factors for postpartum hemorrhage. Uterine atony, or hypotonia of the uterus, is the leading cause of postpartum hemorrhage (PPH). Risk factors for uterine atony include macrosomia (large fetus, > 9 lb), multiple fetuses, hypertension, hydramnios, previous history of atony, high parity (five or more previous deliveries), prolonged labor, induced labor, or trauma during labor (forceps or vacuum-assisted delivery, cesarean delivery). Other risk factors for PPH include unrepaired lacerations, retained placenta, ruptured uterus, inverted uterus, placental abruption, placenta previa, placenta accrete/increta/percreta, or magnesium sulfate administration during labor.
A nurse is caring for a client who is in labor. The anesthesiologist has just administered a pudendal block. Which of the following is correct regarding a pudendal block?
A pudendal block anesthetizes the perineum, vulva, and rectum Rationale: A pudendal block is a type of anesthetic block used for pain control during labor. It is given during the time that the mother is in labor but shortly before the baby is born to help the mother to remain comfortable. A pudendal block anesthetizes the perineum, vulva, and rectum before the infant is delivered. A pudendal block refers to a local anesthetic, such as lidocaine (Xylocaine) or bupivacaine (Marcaine), that is administered transvaginally into the space anterior to the pudendal nerve. A pudendal block provides local anesthesia to the perineum, vulva, and rectum during delivery, episiotomy, and episiotomy repair. It has no maternal or fetal systemic effects. This regional block is administered during the second stage of labor, 10 to 20 min before delivery, and provides analgesia prior to spontaneous delivery of the fetus or to forceps-assisted or vacuum-assisted births. Other considerations: A pudendal block is a localized block to a certain area; it would not cause hypotension and respiratory depression. A pudendal block is typically administered not long before the baby is delivered; it is not one of the first medications administered for pain during labor. A pudendal block may be given before delivery of an infant; it is not only used in emergency situations only.
A nurse is caring for a client who is in labor at 38 weeks of gestation. Which of the following findings indicates the nurse should encourage the client to begin pushing?
Cervix is fully dilated, 100% effaced, and +3 station Rationale: Pushing is encouraged when the cervix is fully dilated, 100% effaced, and the fetal presenting part has descended.
A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta?
Have the mother breast feed the newborn Rationale: Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions. Coughing, sneezing, and laughing can also be used. Causes of uterine prolapse.: Putting pressure on the fundus Asking the mother to bear down Placing gentle pressure on the cord
hypotonic uterine dysfunction.
Oxytocin and Ambulation is indicated for the management of hypotonic uterine dysfunction.
A nurse is caring for a client who is in the third stage of labor. Which best describes the third stage of labor?
The baby has been delivered and the mother is now delivering the placenta Rationale: The third stage of labor occurs after the baby has been delivered and the mother is delivering the placenta. The mother continues to experience contractions, which are designed to push the placenta out. The third stage typically lasts between 5 and 10 minutes. There are three stages of childbirth. The first stage begins from the onset of true labor and lasts until the cervix is completely dilated to 10 cm. The second stage continues after the cervix is dilated to 10 cm until the delivery of the baby. The third stage is the delivery of the placenta. The third stage is the shortest stage.
