Prep-U Ch. 10: Nursing Care during Labor and Birth

A nursing instructor is conducting a session introducing a group of nursing students to the various pieces of equipment used for intermittent fetal monitoring. The instructor determines the session is successful after the students correctly choose which methods can be used? Select all that apply. A. Doppler B. fetoscope C. intrauterine pressure catheter D. external fetal monitor E. Leopold's palpation

A, B, D * Intermittent fetal heart rate auscultation can use a fetoscope, Doppler, or external fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions. Leopold's maneuver is used to determine the position of the fetus so the nurse can locate the best location for listening to the fetal heart, however, the heart rate cannot be determined via this method.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? A. Have the client lightly push to meet the need. B. Have the client pant and blow through the contraction. C. Have the client divert the energy to squeezing a hand. D. Assist the client to a Fowler position.

B. Have the client pant and blow through the contraction. * The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her? A. Lie supine so the tracing does not show a shadow. B. Avoid flexing her knees so her abdomen is not tense. C. Lie on her side so she is comfortable. D. Avoid using her call bell to reduce interference.

C. Lie on her side so she is comfortable. * The best position for all women during labor is on their side.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A. "The warmth and buoyancy of the water has a nice relaxing effect." B. "I can stay in the bath for as long as I feel comfortable." C. "My cervix should be dilated more than 5 cm before I try using this method." D. "The temperature of the water should be at least 105℉ (40.5℃)."

D. "The temperature of the water should be at least 105℉ (40.5℃)." * Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? A. providing pain relief for the mother B. koala care C. making sure the significant other holds the infant shortly after birth D. kangaroo care

D. kangaroo care * If the woman permits it, place the newborn skin-to-skin against her body and place several blankets over them. This technique (called kangaroo care) keeps the infant warm and promotes bonding.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A. Help the woman to sit up in a semi-Fowler's position. B. Turn her or ask her to turn to her side. C. Administer oxygen at 3 to 4 L by nasal cannula. D. Ask her to pant with the next contraction.

B. Turn her or ask her to turn to her side. * The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? A. 5.0 B. 5.5 C. 6.0 D. 6.5

D. 6.5 * Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR? A. over the uterine fundus where contractions are most intense B. above the umbilicus toward the right side of the diaphragm C. between the umbilicus and the symphysis pubis D. between the xiphoid process and umbilicus

C. between the umbilicus and the symphysis pubis * The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. boggy, soft uterus B. uterus becoming discoid shaped C. sudden gush of dark blood from the vagina D. shortening of the umbilical cord

C. sudden gush of dark blood from the vagina * Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first? A. Feel for the fetal buttocks or head while palpating the abdomen. B. Feel for the fetal back and limbs as the hands move laterally on the abdomen. C. Palpate for the presenting part in the area just above the symphysis pubis. D. Determine flexion by pressing downward toward the symphysis pubis.

A. Feel for the fetal buttocks or head while palpating the abdomen. * The first maneuver involves feeling for the buttocks and head at the uterine fundus. Next, the nurse palpates on the side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? A. intact membranes B. cervical dilation (dilatation) of 2 cm or more C. floating presenting fetal part D. a neonatologist to insert the electrode

B. cervical dilation (dilatation) of 2 cm or more * For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation (dilatation) of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

Which assessment finding is most important as labor progresses? A. The client is remaining in control of emotions. B. Labor is completed within 18 hours. C. The uterus relaxes completely between contractions. D. The pulse and respirations rise with the work of labor.

C. The uterus relaxes completely between contractions. * It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.

At what time is the laboring client encouraged to push? A. When the nurse wants the client to push B. When the health care provider has arrived C. When the cervix is fully dilated D. When the fetal head can be seen

C. When the cervix is fully dilated * To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.