12. Intrapartum Basics
longitudinal lie
-fetal spine is parallel to mother's spine -fetus is in cephalic or breech presentation
physical signs of transition phase (3)
-urge to push -rectal pressure, feels need to have BM -nausea, vomiting
assessment of contractions (4)
-frequency -duration -intensity -resting tone of uterus
active phase: contraction frequency and duration
-frequency: 3-5 min -duration: 40-70 sec
3 phases of 1st stage
-latent phase -active phase -transition phase
amniotic fluid: appearance, volume
-watery, clear, pale yellow/straw-colored -500-1,200 mL
rate of cervical dilation
-primigravida: 1 cm/hr -multigravida: 1.5 cm/hr
flashcards
https://www.freezingblue.com/flashcards/print_preview.cgi?cardsetID=256737
5 P's of labor
-Passenger (fetus and placenta) -Passageway (birth canal) -Powers (contractions) -Position (of the woman) -Psychological response
length of 3rd stage
5-30 min (placenta)
A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time? a. Decreased blood pressure and increased pulse b. Increased blood pressure and increased pulse c. Decreased blood pressure and decreased pulse d. Increased blood pressure and decreased pulse
a. Decreased blood pressure and increased pulse text
Leopold maneuvers
abdominal palpation to determine presentation and position of fetus and aid in location of fetal heart sounds -# of fetuses -presenting part -fetal lie -fetal attitude -degree of descent -location of fetus' back to assess for fetal heart tones
contraction frequency
beginning of 1 contraction to beginning of next
The nurse is evaluating an intrapartum client's lab results. Which laboratory finding should the nurse report to the physician or nurse-midwife? a. Hematocrit: 45% b. Leukocyte count: 19,000/mm c. Platelets: 120,000/mm d. White blood count: 11,000/mm
c. Platelets: 120,000/mm -abnormally low, thrombocytopenia -normal platelet count = 150,000-500,000/mm text
cervical ripening
cervix becomes soft and partially effaced, and can begin to dilate
fetal extension
chin extended away from chest, extremities extended
frequency of assessment during transition phase
every 15-30 min
sacral counterpressure
pressure applied using heel of the hand against pt's sacral area to counteract pain in lower back
When the presenting part is the fetal head, which cardinal movement occurs when resistance from the pelvic structures during contractions causes the fetal chin to be tucked onto the chest and the spine to curve ventrally? a. Descent b. Flexion c. Internal rotation d. Restitution
b. Flexion text
A nurse is planning to perform Leopold's maneuvers on a laboring client. What should be the nurse's initial action? a. Position the client in a supine position. b. Have the client void. c. Wash hands in warm water. d. Apply sterile lubricant to the abdomen.
b. Have the client void. (improved comfort for pt) text
A client at 39 weeks' gestation calls the clinic nurse to report increasing pelvic pressure, increased energy, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of: a. A vaginal infection. b. Impending labor. c. A urinary tract infection. d. Rupture of membranes.
b. Impending labor. text
The nurse is caring for four laboring clients in the first stage of labor. Which client is demonstrating responses commonly seen during the latent phase? a. A client with increased fatigue, restlessness, and anxiety b. A client with increased irritability who is feeling out of control c. A client who is happy and talkative d. A client who has just delivered a healthy newborn
c. A client who is happy and talkative text
A nurse is reviewing the factors important in the process of labor. Which two pelvic types are favorable for labor and vaginal delivery? a. Gynecoid and android b. Platypelloid and anthropoid c. Gynecoid and anthropoid d. Android and platypelloid
c. Gynecoid and anthropoid text
A laboring client complains of nausea, vomiting, and increasing rectal pressure. She states, "I can't take this anymore." The nurse correctly assesses that this client is in which phase of labor? a. Latent b. Active c. Transition d. Second stage
c. Transition text
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8cm and reports back pain. Which of the following actions should the nurse take? a. perform transcutaneous electrical nerve stimulation (TENS) b. assist with biofeedback c. apply sacral counterpressure d. initiate slow-paced breathing
c. apply sacral counterpressure ATI
A nurse is caring for a client who is in labor. A vaginal exam reveals the following information: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this info, which of the following fetal positions should the nurse document in the medical record? a. transverse b. breech c. vertex d. mentum
c. vertex ATI
dilation
-enlargement of cervical os and cervical canal during the 1st stage of labor -process of the cervix opening during labor
fetal position terminology
-right (R) or left (L): references either side of the maternal pelvis -occiput (O), sacrum (S), mentum (M), scapula (Sc): presenting part of the fetus -anterior (A), posterior (P), transverse (T): references the part of the maternal pelvis ex: -LOP = left occipitoposterior -ROA = right occipitoanterior
contraction intensity
strength of contraction at its peak, assessed by palpation
contraction duration
time between beginning to end of same contraction
A low-risk client's vaginal exam reveals that her cervix is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this client's vital signs? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes
d. Every 30 minutes -pt is in the transition phase of 1st stage of labor - assess vitals every 30 min -more frequent assessment of vitals during 2nd and 3rd stages text
A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal position should the nurse expect to see written on the client's chart? a. Right-occiput-anterior (ROA) b. Left-mentum-transverse (LMT) c. Right-sacrum-anterior (RSA) d. Left-occiput-posterior (LOP)
d. Left-occiput-posterior (LOP) (Either occiput-posterior (LOP or ROP) position of the fetus would cause a woman to complain of intense backache, as the fetal head presents a larger diameter in the posterior position.) text
stages of labor
-1st stage: onset of regular contractions (true labor) → full effacement and dilation -2nd stage: cervix fully dilated → birth -3rd stage: birth → placenta delivery -4th stage: placenta delivery → 4 hrs after birth
pt behavior: active phase (2)
-anxiety -feelings of helplessness
station
-measurement of fetal descent in cm -0 = at ischial spine -minus station = ↑ ischial spine -plus station = ↓ ischial spine
presentation, presenting part
-portion of the fetus that enters the pelvic passage 1st and leads through the birth canal during labor -cephalic, breech, shoulder
Assessment reveals that the fetus of a primigravida is at +1 station. The interpretation of this finding is indicating that the presenting part of the fetus is at which of the following positions? A. 1 cm above the ischial spines B. 1 cm below the ischial spines C. 1 cm above the ischial tuberosities D. 1 cm below the sacral promontory
B. 1 cm below the ischial spines disc
A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first? A. Check the amniotic fluid for meconium B. Monitor FHR for distress C. Dry the client and make her comfortable D. Monitor uterine contractions
B. Monitor FHR for distress (greatest risk is umbilical cord prolapse, leading to fetal distress following rupture of membranes) ATI
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers D. Stand facing client's feet with fingertips outlining cephalic prominence
B. Palpate the fundus of the uterus ATI
pt behavior: latent phase
talkative and eager
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2. Assess the client's temperature every 2 hours. 3. Schedule a daily ultrasound to assess fetal movement. 4. Schedule a non-stress test every 4 hours to assess fetal well-being.
1. Assess for signs and symptoms of labor. (As a result of the sedative effect of the Mg sulfate, the client may not perceive labor) NCLEX
A nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes and have a duration of 35 seconds. Using this information, what is the most appropriate action for the nurse to take? 1. Prepare for imminent delivery. 2. Continue to monitor the client. 3. Report the findings to the obstetrician. 4. Report the FHR to the anesthesiologist on call.
2. Continue to monitor the client. (The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring) NCLEX
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction
2. Every 15 minutes NCLEX
A nurse in L&D is caring for a client in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced and the fetus is at a -2 station. Which of the following stages and phases of labor is this client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor
A. First stage, latent phase latent phase: -dilation: 0-3 cm -contraction frequency: 5-30 min -contraction duration: 30-45 sec ATI
The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."
3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." NCLEX
The nurse assesses a laboring client whose contractions occur every 5-7 minutes and last for 30 seconds. In which phase of labor is this client most likely to be? a. Latent b. Active c. Transition d. Second
a. Latent -contraction duration >30 sec in active and transition phases -active = contractions every 3-5 min -transition = contractions every 2-3 min text
A pregnant client asks the nurse, "How will I know when I am close to starting labor?" The nurse correctly states that one possible sign of impending labor is: a. Loss of weight. b. Increase in appetite. c. Feeling of fatigue. d. Abdominal discomfort.
a. Loss of weight. -diarrhea, indigestion, nausea and vomiting usually occur just prior to the onset of labor -some women report a sudden burst of energy 24-48 hr before labor -abdominal discomfort = false labor text
malpresentation
-breech and shoulder -associated with difficulties during labor
premonitory signs of labor (9)
-lightening -Braxton Hicks contractions -↑ vaginal discharge or bloody show -energy burst, "nesting" -cervical ripening -lower backache -rupture of membranes -weight loss (0.5-1.5 kg/1-3 lb) -GI: nausea, vomiting, indigestion
nursing interventions during labor (5)
-mother/fetal monitoring -encourage voiding every 2 hr -encourage frequent position changes -nonpharmacological pain management -provide pharmacological pain relief
length of 1st stage
-primigravida: 8-10 hr -multigravida: 2-10 hr
true labor vs. false labor - contractions
-true labor: contractions regular -false labor: contractions irregular -true labor: intensity ↑ with walking -false labor: intensity ↓ with walking
true labor vs. false labor - pain
-true labor: lower back pain -false labor: epigastric pain, above umbilicus
Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1. "I feel like I need to push." 2. "My contractions seem to be getting stronger." 3. "I am glad that I have several minutes to rest between contractions." 4. "Warm fluid is running down my legs each time I have a contraction."
1. "I feel like I need to push." (2nd stage of labor begins when the cervix is completely dilated and ends with birth of the infant - the laboring woman typically experiences the desire to push) NCLEX
breech presentation variations
3 variations: 1. frank: butt is presenting 2. full/complete: butt and feet are presenting 3. footling: foot is presenting
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation? (select all that apply.) A. Lengthening of the umbilical cord B. Swift gush of clear amniotic fluid C. Softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation
A. Lengthening of the umbilical cord D. Appearance of dark blood from the vagina E. Fundus firm upon palpation ATI
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following should statements the nurse include in the teaching? (select all that apply.) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."
B. "It can detect abnormal fetal heart tones early." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity." ATI
A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following responses should the nurse make? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."
C. "The vaginal area will bulge as the baby's head appears." ATI
A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client is very irritable and feels the urge to have a BM. She states, "I've had enough. I can't do this anymore. I want to go home right now." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth stage C. Transition phase D. Latent phase
C. Transition phase (transition phase occurs when pt becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis) ATI
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? a. "A full bladder increases the risk for fetal trauma." b. "A full bladder increases the risk for bladder infections." C. "A distended bladder will be traumatized by frequent pelvic exams." D. "A distended bladder reduces pelvic space needed for birth."
D. "A distended bladder reduces pelvic space needed for birth." ATI
A nurse assesses a rise in the fundal height and a sudden gush of blood from the vagina of a postpartum client 5 minutes after birth. The nurse appropriately interprets these finding as: a. Immediate postpartum hemorrhage. b. Separation of the placenta. c. Late postpartum hemorrhage. d. Delivery of the placenta.
b. Separation of the placenta. text
lightening symptoms (3)
fetal head descends into pelvis -feeling that fetus has "dropped" -easier breathing -pressure on bladder
effleurage
light circular stroking of the abdomen -pain management, facilitates relaxation during labor -provide tactile stimulation to the fetus
attitude
relationship of fetal body parts to one another (flexion, extension)
A G4P3 client who has just entered the second stage of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide? a. One hour b. Two hours c. Three hours d. Four hours
a. One hour -multipara: <1 hr -nullipara: <2 hr text
A G1P0 client at 39 weeks' gestation arrives at the birthing center with irregular contractions ranging from 10 to 30 minutes apart. Assessment data reveals 1-2cm cervical dilation, membranes intact, and a thick cervix. What would be the most appropriate nursing action at this time? a. Send the client home to rest. b. Admit the client to the birthing center. c. Begin to hydrate the client with IV fluids. d. Monitor the client with pelvic checks every hour.
a. Send the client home to rest. (A client with contractions 10-30 min apart and 1-2cm cervical dilation, membranes intact, and a thick cervix is in the latent phase of early labor. Send the client home to rest and conserve her energy for active labor. The client will be admitted only when she begins active labor.) text
The physician orders internal fetal monitoring for a laboring client. What criterion must the client meet prior to this procedure? a. The fetal part must be engaged. b. The membranes must be ruptured. c. The cervix must be dilated to 4 cm. d. The fetus must be in an occiput-anterior position
b. The membranes must be ruptured. text
A nurse is performing intermittent auscultation in the active phase of the first stage of labor at term after a low-risk pregnancy. The fetal heart rate is 140 at 5 p.m. What would be an indication for checking it again before 5:30? a. A burst of fetal activity b. If blood-streaked mucous were noted on the peri pad c. If the mother reported a gush of fluid d. Immediately after an episode of vomiting
c. If the mother reported a gush of fluid (when monitoring fetal well-being in a low-risk pt, FHR should be auscultated every 30 min in the active phase of 1st stage of labor and after ROM) text
A G3P0 client in active labor is admitted to the birthing center. Which data set should the nurse interpret as being within the normal range? a. Temperature 98.6°F and pulse 46 b. Temperature 98.4°F and blood pressure 142/90 c. Temperature 100.8°F and pulse 88 d. Temperature 99.4°F and blood pressure 130/88
d. Temperature 99.4°F and blood pressure 130/88 normal vitals during 1st stage of labor: -BP: 90/60-140/90 -pulse: 60-90 -respirations: 12-20/min -temp: <99.6°F text
cephalic presentation variations
head-first 4 variations: 1. vertex: head flexed into chest (complete flexion) 2. military/sinciput: head neither flexed nor extended (moderate flexion) 3. brow: head partially extended (poor flexion) 4. face: head is hyperextended (full extension)
length of 2nd stage
-primigravida: 30 min-2 hr (<2 hr) -multigravida: 5-30 min (<1 hr) (birth of baby)
lie
-relationship of the spine of the fetus to the spine of the mother -longitudinal or transverse
rupture of membranes (ROM)
-spontaneous ROM can initiate labor or can occur anytime during labor, most commonly during the transition phase -labor usually occurs within 24 hr of the ROM -prolonged ROM >24 hr before delivery of fetus can lead to an infection.
fetal position
-the relationship of the presenting part of the fetus in reference to its directional position as it relates to 1 of the 4 maternal pelvic quadrants -labeled with 3 letters
A nurse is preparing to perform Leopold maneuvers for a client. Place the following steps in the correct order: a. Identify the attitude of the head. b. Palpate the fundus to identify the fetal part. c. Determine the location of the fetal back. d. Palpate for the fetal part presenting at the inlet.
1. Palpate the fundus to identify the fetal part. 2. Determine the location of the fetal back. 3. Palpate for the fetal part presenting at the inlet. 4. Identify the attitude of the head. ATI
The purpose of a vaginal examination is to specifically assess the status of which findings? (Select all that apply) 1. Station 2. Dilation 3. Effacement 4. Bloody show 5. Contraction effort
1. Station 2. Dilation 3. Effacement (station, dilation, effacement, position, status of membranes) NCLEX
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.
2. Assess the baseline fetal heart rate. NCLEX
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus.
2. Continue to monitor the client. -everything is WNL -signs of potential complications of labor are contractions consistently lasting ≥90 sec or consistently occurring ≤2 min apart NCLEX
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids
2. Rest between contractions NCLEX
The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis
3. 1 cm above the ischial spine NCLEX
The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the fetal heart rate every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes.
3. Encourage an upright or side-lying maternal position. NCLEX
The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1. Noting whether the heart rate is greater than 140 beats/min 2. Placing the diaphragm of the Doppler on the mother's abdomen 3. Palpating the maternal radial pulse while listening to the fetal heart rate 4. Performing Leopold's maneuver first to determine the location of the fetal heart
3. Palpating the maternal radial pulse while listening to the fetal heart rate NCLEX
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."
4. "My contractions will increase in duration and intensity." NCLEX
The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control
4. Fear of losing control (Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the 1st stage of labor) NCLEX
An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1. Light green, with no odor 2. Clear and dark amber-colored 3. Thick and white, with no odor 4. Pale straw-colored, with flecks of vernix
4. Pale straw-colored, with flecks of vernix -greenish = meconium -amber-colored = bilirubin -thick white = infection NCLEX
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation
4. Placental separation NCLEX
The nurse is caring for a client in the transition phase of labor. What objective data would indicate that the client is having increased pain? a. Dilated pupils and increased blood pressure b. Muscle tension and decreased blood pressure c. Decreased respiration and increased blood pressure d. Increased pulse and decreased blood pressure
a. Dilated pupils and increased blood pressure text
A nurse is auscultating the heart rate of a fetus in a cephalic presentation. In which location would the nurse hear the heart rate most clearly? a. The lower quadrant of the maternal abdomen b. Level of the maternal umbilicus c. The upper quadrant of the maternal abdomen d. Above the apex of the fetal heart
a. The lower quadrant of the maternal abdomen -umbilicus = transverse presentation -upper quadrant = breech presentation -FHR heard most clearly along the back of the fetus, not apex of heart text
A G1P0 client calls the hospital and says to the nurse, "I think I am having labor pains. When should I come to the hospital?" The nurse correctly replies that the client should come in when her contractions are: a. 3 minutes apart for 30 minutes. b. 5 minutes apart for 1 hour. c. 5-10 minutes apart for 30 minutes. d. 10-15 minutes apart for 1 hour.
b. 5 minutes apart for 1 hour. (The nullipara client should come in when her contractions are 5 min apart for 1 hr. The multigravida client should come when contractions are 3 min apart for 30 min.) text
A healthy, pregnant woman asks the nurse about the best way to monitor her baby's status when she is in labor. The nurse knows that continuous electronic fetal monitoring: a. Has been proven to improve outcomes for the newborn. b. Can be done via telemetry to allow ambulation. c. Is superior to intermittent auscultation. d. Is not evidence-based and should never be done.
b. Can be done via telemetry to allow ambulation. text
The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid.
1. Determine the fetal heart rate. (When the membranes rupture in the birth setting, the nurse immediately assesses FHR to detect changes associated with prolapse or compression of the umbilical cord) NCLEX
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? (Select all that apply) 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The spontaneous urge to push is initiated from perineal pressure.
3. The cervix is dilated completely. 5. The spontaneous urge to push is initiated from perineal pressure. (2nd stage begins when cervix is dilated completely and ends with birth of neonate) NCLEX
effacement
shortening and thinning of the cervix during the 1st stage of labor
bloody show
-expulsion of cervical mucous plug -brownish or blood-tinged -24-48 hrs before labor onset
pt behavior: transition phase (3)
-feels out of control -"cannot continue" -irritability, frustration
transverse lie
-fetal spine is perpendicular to mother's spine -shoulder presentation -delivery by c-section is necessary
second stage: contraction frequency and duration
-frequency: 1-2 min -duration: 60-90 sec
latent phase: contraction frequency and duration
-frequency: 5-30 min (ATI), 10-30 min (text) -duration: 30-45 sec
cervical dilation each phase of 1st stage
-latent: 0-3 cm -active: 4-7 cm -transition: 8-10 cm
fetal flexion
-normal fetal attitude -chin flexed to chest, extremities flexed into torso
non-pharmacological pain management (7)
-patterned breathing -frequent position changes -effleurage -sacral counterpressure -walking -application of heat or cold -therapeutic touch and massage
transition phase: contraction frequency and duration
ATI, NCLEX: -frequency: 2-3 min -duration: 45-90 sec text: -frequency: 1.5-2 min -duration: 60-90 sec
A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. Assist the client to the bathroom B. Prepare for an impending delivery C. Prepare to remove a fecal impaction D. Encourage the client to take deep, cleansing breaths
B. Prepare for an impending delivery (urge to have bowel movement = complete descent and dilation) ATI
A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the itroitus for a prolapsed cord B. Perform a test to identify the ferning pattern C. Monitor station of the presenting part D. Defer vaginal examinations
D. Defer vaginal examinations (vaginal exams shouldn't be performed until placenta previa or abruptio placentae has been ruled out) ATI
resting tone of uterine contractions
tone of uterine muscle between contractions
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
transition phase -rectal pressure -dilation = 8-10 cm -contraction frequency = 2-3 min -contraction duration = 45-90 sec ATI
engagement
when the widest diameter of the presenting part has passed the inlet; corresponds to a 0 station
A nurse in the L&D unit receives a phone call from a client who reports that her contractions started about 2 hr ago, did not go away when she had 2 glasses of water and rested, and became stronger since she started walking. Her contractions occur every 10 min and last about 30 sec. She hasn't had any fluid leak from her vagina. However, she saw some blood when she wiped after voiding. Based on this report, which of the following critical findings should the nurse recognize that the client is experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions
D. True contractions (contractions don't go away with hydration or walking; they are regular in frequency, duration, and intensity and become stronger with walking) ATI
A nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. contractions that last for 60 sec each with a 4-min rest between contractions b. contractions that last for 60 sec each with a 3-min rest between contractions c. a contraction that lasts 4 min followed by a period of relaxation d. contractions that last 45 sec each with a 3-min rest period between contractions
b. contractions that last for 60 sec each with a 3-min rest between contractions -measure contraction interval from beginning of 1 contraction to beginning of next contraction -a contraction lasting 60 sec with a relaxation period of 3-min = contractions every 4 min ATI
The nurse is caring for a client at 37 weeks' gestation who has gestational hypertension and is in the active phase of labor. How frequently should the nurse assess the fetal heart rate? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every hour
b. Every 15 minutes text
A G4P3 at term presents to the labor and birth unit apparently in active labor. Her birth plan states she is an Orthodox Jew and that she would like to observe her religious traditions around childbirth. Her husband hugs her, states he will be in the waiting room, and leaves the client alone with the nurse. What is the most appropriate nursing response? a. Assess the client for signs of domestic abuse. b. Reassure the client that the nursing staff will be present and supportive. c. Encourage the husband to participate in the labor and birth process. d. Tell the client that most fathers are present for the birth of their children.
b. Reassure the client that the nursing staff will be present and supportive. text
A nurse is performing a vaginal examination for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take? a. perform effleurage during contractions b. place the pt in lithotomy position c. assist pt to hands and knees position d. apply scalp electrode to the fetus
c. assist pt to hands and knees position (position can help relieve back pain and will enable the rotation of the fetus from the posterior to an anterior occiput position) ATI
A laboring client asks the nurse how often she is having contractions. Which method of measuring the interval between contractions will enable the nurse to give an accurate answer to client's question? a. Determine the interval between the acme of one contraction and the acme of the next. b. Determine the interval between the end of one contraction and the beginning of the next. c. Determine the interval between the contractions that are strong to palpation. d. Determine the interval between the beginning of one contraction and the beginning of the next.
d. Determine the interval between the beginning of one contraction and the beginning of the next. text
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? a. keep 4 side rails up while the client is in bed b. monitor the FHR every hour c. insert an indwelling urinary catheter d. check the cervix prior to analgesic administration
d. check the cervix prior to analgesic administration -only need side rails up if medicated, pts like to walk during labor -FHR should be monitored more frequently -catheter is not necessary -analgesia administered too close to delivery could cause respiratory depression in newborn ATI
frequency of assessment during active phase
every 30 min
frequency of assessment (BP, pulse, respirations) during latent phase
every 30-60 min