PrepU Chapter 10

A client is ready to push. The nurse instructs her to push vigorously by taking a deep breath and pushing hard while counting to 10. The nurse tells her to do three of these maneuvers during the contraction. What would be important to monitor on the client while she is pushing vigorously?

heart rate

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next.

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?

cervical dilation of 2 cm or more

The labor and delivery nurse has responsibility for monitoring fetal heart rate patterns. Which of the following values would indicate fetal tachycardia?

> 160 bpm

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which of the following statements?

"Anxiety can speed up the labor process."

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain."

A woman is admitted to a labor unit in active labor. Which of the following assessments would alert you to the possibility that she may have difficulty accepting this child?

"I want this baby to be a boy."

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?

"Unfortunately, I'm going to have to stay quite still in bed while it is in place."

The nurse assesses her client and notes that the fetus is at +1 station. The nurse interprets +1 station as indicating that the fetal presenting part is at:

1 cm below the ischial spine.

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?

6.5

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate.

As the obstetric nurse you are monitoring your client during the third stage of labor. You know that you need to monitor her for any sudden change in status that might indicate the development of an amniotic fluid embolism. What would indicate such an embolus?

Chest pain

It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following?

Deep variable decelerations more than 60 bpm below the baseline with every contraction.

Mrs. Timms is now in the transition phase of labor. One of your concerns is the possibility of an ineffective breathing pattern. If one of your goals was for the woman's breathing pattern to be effective, what outcome would you expect?

Does not hyperventilate

When assessing a client in labor, the nurse observes that the fetal heart rate (FHR) gradually falls from 150 bpm to 132 bpm during the contraction and returns to baseline at the end of the contractions. The nurse interprets this finding as associated with which of the following?

Fetal head compression

As your client progresses through the fourth stage of labor, or recovery, you make 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?

Kangaroo care

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?

The uterus contracts and squeezes the cord against the fetus.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme

Which action is a priority when caring for a woman during the fourth stage of labor?

assessing the uterine fundus

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

When applying the ultrasound transducers for continuous external electronic fetal monitoring, the nurse would place the transducer to record the FHR at which location?

between the umbilicus and the symphysis pubis

A patient arrives at the birthing suite and tells the nurse that she is in labor. Which of the following should the nurse immediately assess at this time? (Select all that apply.)

birth imminence fetal status risk factors maternal status

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with a Nitrazine swab and confirms membrane rupture if the swab turns:

blue.

A client is now in the second stage of labor. While doing the assessment, the nurse would gather what data at this time?

contraction pattern every 15 minutes

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

A woman has just entered the second stage of labor. The nurse would focus care on which intervention?

encouraging the woman to push when she has a strong desire to do so

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?

every 15 minutes

As a woman enters the second stage of labor, which would the nurse expect to assess?

feelings of being frightened by the change in contractions

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor. The earlier baseline FHR was 140. The FHR now is 168. The nurse knows that which factors can affect changes in the FHR? Select all that apply.

fetal movement fetal distress maternal fever

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? (Select all that apply.)

frequency duration intensity

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

infection

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient?

latent phase

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?

moderate

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?

placenta previa

When an examiner does an initial vaginal examination on a patient in labor, he or she is confirming which of the following? (Select all that apply.)

presentation position attitude fetal station

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

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?

sudden gush of dark blood from the vagina

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and a falling blood pressure

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:

-2 station.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions.

While monitoring the EFM tracing the nurse notes decelerations with each contraction. The nurse knows that for a deceleration to be classified as early it has to meet three criteria. What is one of these criteria?

The nadir of the deceleration coincides with the acme of the contraction.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed