womens exam 3
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia."
The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby?
1 cm below the ischial spine
oxytocin is only given 1. ________ , and requires 2. ______ and 3. ______
1. IVPB 2. Eternal fetal monitor 3. FHR
Nurse would suspect a cord prolapse if there was a _______ AFTER the dr. Performed an _______
1. fetal heart deceleration 2. amniotomy
interventions for hyperstimulation and reassuring fetal HR
1. side lying 2. turn off oxytocin 3. increase iv rate 4. O2 face mask @ 8-10L 5. Notify PCP
how much should the nurse check the client during the latent phase active phase transiontional phase
30 - 60 minutes : latent every 30 minutes : active 15- 30 minutes : transitonal continously : internal fetal monitor
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
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
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?
massage the woman's back
best pelvis shape -
gynecoid
what people would be involved with a cord prolapse
NICU nurse, anesthesia , charge RN , obstetrician
factors affecting labor ( 5 P's )
Passenger (size of babys head) Passageway Powers (contractions ) Position Psychology
difference between general , regional , and local anesthesia
General anesthesia - for emergencies in which the fetus must be delivered immediately to save the life of the fetus, mother or both. Regional anesthesia - pain relief during labor and birth. Local anesthesia - short-acting anesthesia used to numb the perineum.
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.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
Change the position of the client.
A client received IV nalbuphine in labor. The labor progressed rapidly and the nurse is preparing for the birth of the neonate less than 1 hour later. What medication will the nurse ensure is available immediately after birth of the neonate?
Naloxone - opioid antagonist used to reverse the respiratory depression if needed.
The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?
The fever may be due to the epidural."
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize?
The priority is to establish the imminence of the birth, then the fetal status.
explain the how to properly implement the leopald's maneuver
first maneuver : feel for the buttcheeks and head at the fundus. second maneuver : palpate on the side the fetal back is located. third maneuver - determine presentation and palpating the area just above the symphysis pubis. final maneuver - determines attitude and apply downward pressure in the direction of the symphysis pubis.
fetal malpresentation : frank - complete - footling -
frank - criss cross ass first complete - criss cross feet first footling - foot presenting
what puts a woman at risk for preterm labor ?
gestational age, early contractions, or early progressive cervical change
how is an amniotic fluid embolism caused ?
when debris in amniotic fluid enters the moms circulation and obstructs the pulmonary vessels causing respiratory distress
when a mother is diagnosed with preterm labor what nursing intervention should be implemented
-put patient on bed rest -give tocolytics : (terbutaline, mag, indomethacin, nifedipine )
The nurse is reviewing a pregnant client's birth plan. The client asks the nurse about the use of opioids during the labor process. How will the nurse respond?
"You will feel less pain during the contractions, but will still feel some of the pain."
ruptured uterus: signs -
-silent/ non-reassuring HR -signs of shock -sudden sharp pain -Bandl's ring ( dent in belly )
what reasons would you use an oxytocin infusion
-tetanic contractions -placental abruption -uterine rupture -lacerations of the cervix -postpartum hemmorhage -hyperstimulation
signs and symptoms of preterm labor
- contractions/cramping -suprapubic pain/pressure -peeing a lot -discharge -ROM
what reasons would a mom need to get an induction
- gestational HTN - diabetes - postterm - IUGR ( baby does not grow as expected) - mom has a HX or rapid labor - baby died ( IUFD)
risk that could lead to a prolapse cord
- long cord -fetus floating or unengaged -breech presentation
what test would you use to diagnose preterm labor
- salivary Estriol test - check endocervical length : ( short cervix = early labor) - Fetal fibronectin
what are the different ways a mom can be induced through
- sex -foley - oil/herbs -acupunture -enema - amniotomy ( stripping oxytocin )
A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block?
- spinal abnormality - hypovolemia - coagulation defects
what indications would indicate a need for a c-section
-abnormal FHR -cord prolapse -malpresentation -dysfunctional labor -multiple fetus
causes of a ruptured uterus
-uterine contractions -induction/augmentation -over distended uterus -uterine trauma -previous c-section -prolonged labor
interventions for Amniotic fluid embolism
1. call for help 2. O2 3. maintain cardiac output and replace fluid lost 4. monitor fetal & maternal status 5. prepare for emergency birth once stabilized 6. give emotional support
interventions for prolapsed cord :
1. call for help 2. trendelenburg ( knee chest or w/ hips elevated )\ 3. keep hand in patients vagina and feel for pulse 4. Notify PCP 5. prepare for immediate C-section
1st stage of labor : latent , active and transitional begins with __ and ends with ___ , dilation is __ 2nd stage of labor : begins with ___ and ends with ___ dilation is ___ 3rd stage : begins with ____ and continues ____
1st : onset of contractions to complete dilation latent 0-3, active - 4-7 , transitional 8-10 2nd ( expulsion ) : begins with complete dilation (10 cm ) and ends when baby is delivered 3rd : begins when placenta is delivered and continues 1-4 hours after delivery
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize
Continue with the admission assessment
Effacement is - At 0%, - at 50% - at 100% -
Effacement - the length of the cervical canal. At 0%, the cervical canal is 2 cm long at 50%, 1 cm long at 100%, the cervical canal is obliterated.
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?
Encourage her through the contractions, explaining why she cannot receive any pain medication.
oxytocin infusion : P - I - T - O- C - I - N -
P - pressure elevated I - I & O T - tetanic contractions O- O2 decrease in fetus C - Cardiac ( arrhythmia ) I - irregular FHR N - N/V
what is shoulder dystoica - nursing actions - (helperr)
SD - ( EMERGENCY ) baby's shoulder is caught on moms pubic bone NA : H - call for help E - episiotomy L - legs ( McRoberts maneuver ) P - pressure ( suprabubic ) E - enter vagina to turn baby R - remove posterior arm R - roll patient to hands and knees
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?
Use a birthing ball and find a position of comfort.
a client in the second stage of labor has been screaming. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
ask the CLIENT to rate her pain 1-10
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
assess her labor progression
what is APGAR used for what is tested on the Apgar score ?
assess the newborn at 1 min and 5 min after birth heart rate - absent, under 100, over 100 respiratory - absent , slow/irregular, cry muscle tone - limp, some flexion, active movement reflex irratabiltiy - absent, grimace, cry color - pale , pink body blue extremities, all pink
what signs happen preceding labor labor
bloody show lightning cervix ripens (softens ) burst of energy
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?
check chart for the last time the client voided
when a mom is scared during labor, what can happen physically and chemically
chemically - oxytocin and endorphins (block pain receptions) decreases physically - blood flow to the uterus decreases
what should be assessed during the assessment of ROM
color, viscosity, odor, amount
A client is now in the second stage of labor. While doing the assessment, which data should the nurse prioritize?
contraction patterns every 15 minutes
ruptured Uterus: delivery type - may have to have -
delivery type : emergency c-section may have : - laparotomy & Hysterectomy -blood transfusion
what is tested in a bishop score - what is the purpose of it - what score is would be considered good -
dilation, effacement, station, cervix , cervical dilation (from 1 being the lowest - 3) purpose - evaluates readiness of mom for a induction good score - 8 & ^
dystocia definition - signs that "dystocia" is taking place - nursing actions to implement -
dystocia - long, difficult, and abnormal labor s/s - no change in dilation, effacement or fetal station NA : - encourage ambulation - postion changes ( hands and knees )
in early active labor how often would the nurse assess the FHR
every 15-30 min.
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
green colored fluid in the vagina
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?
have the client pant and blow though the contraction
which incision is better for a c-section
horizontal - ( better healing ) (vertical has high risk for uterine rupture )
Which assessment finding is most important as labor progresses?
important that the uterus relaxes completely between contractions
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
inability to push
Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?
inspect the perineum
what is the tool used for an amnioinfusion what disorders would it be needed for
intrauterine pressure catheter indications : -variable decels -ROM -meconium -oligohydramnios
Which opioid can the nurse offer to the client to assist with pain control?
merpidine
after delivering a baby who has experience should dystocia, what should the nurse be prepared to do and what should be examined ?
nurse should prepare to resusciatae the infant and examine for fractured clavicles, movement, and tone or upper extremities
when would a pregnancy be considered postterm - what could possibly happen to mom - what could possibly happen to baby - management =
over 42 weeks mom : -trauma -postpartum hemmorhage, -c-section -monoclonial antibody baby : -dystocia -trauma -decreased perfusion managment; -daily kick counts -biophysical profile -NST - induction
what is hyperstimulation
overhyperstimulation - exaggerated response to excess hormones when women are taking medication for better development of eggs in the ovaries ( causes ovaries to hurt & swell )
what is the number one cause of neonates dying
preterm birth
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
what medication can you use as a cervical ripening method - what mechanical dilator can use for cervical ripening -
prostglandin E, cervidil, cytotec ballon catheter
Massage is an effective nonpharmacologic technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism?
releases endorphins
amniotic fluid embolism symptoms
respiratory distress circulatory collapse hemorrhage
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
respiratory status
To assess the frequency of a woman's labor contractions, the nurse would time:
the beginning on one contraction to the next
what is a prolapsed cord ?
when the umbilical cord lies below the presenting part of the fetus blocking the baby's exit
signs of the onset of labor
-decreased progesterone -aging of placenta -uterine distention -increased estrogine, prostaglandins , and uterine pressure
The nurse will be performing the Leopold maneuver to determine the position of the fetus. List in order the steps that the nurse would take
-determine presentation -determine positon -confirm presentation -determine attitude
signs of a prolapsed cord 1. - 2. -
-fetal bradycardia w/ variable decelerations -cord is seen or felt protruding from vagina
factors affecting the passage way
-lower uterine segment -cervix : effaces (things) , dilates (opens ) -pelvic floor : muscular layer that separates cavity from perineal space below -vagina : stretches to accommodate fetus -introtius : external opening to vagina
Monitor interventions MAB
-monitor FHR -empty bladder -assess newborn for trauma
what factors effect the "passageway" during labor ( baby coming out vagina)
-placenta previa -uterine fibroids in lower segment -full bladder/rectum
