404 Ch. 14: Nursing Management During Labor and Birth

A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? a. "The anesthesiologist will do her best to avoid this." b. "Spinal headache is not a usual complication of epidural blocks." c. "Your health care provider knows what is best for you." d. "The pain relief offered will compensate for the discomfort afterward."

b. "Spinal headache is not a usual complication of epidural blocks."

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 in response? a. Print a copy of the instructions for the doula to sign b. Continue with the admission assessment c. Determine what activities the doula is qualified to handle d. Ask the client who she would like to see first

b. Continue with the admission assessment

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: a. effleurage. b. therapeutic touch. c. patterned breathing. d. acupressure.

a. effleurage.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? SATA a. Administer oxygen by mask. b. Turn the client on her left side. c. Assess client for underlying causes. d. Ignore questions from the client. e. Reduce intravenous (IV) fluid rate.

a, b, c

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? a. Maternal hypotension b. Maternal fatigue c. Uteroplacental insufficiency d. Cord compression

c. Uteroplacental insufficiency

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? a. Urinalysis b. Leopold maneuver c. Nonstress test d. Vaginal examination

d. Vaginal examination

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?

rupture of membranes

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? a. 10:30 a.m. b. 11:30 a.m. c. 10:05 a.m. d. 11:15 a.m.

a. 10:30 a.m.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? a. Notify the registered nurse. b. Notify the health care provider. c. Assess and reposition the woman. d. Wait 2 minutes to review another tracing.

c. Assess and reposition the woman.

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? a. Rapid progress of labor b. Urinary retention c. Dry, cracked lips d. Inability to push

d. Inability to push

Which statement is true regarding analgesia versus anesthesia? a. Increased FHR variability is a common side effect when regional anesthesia is used. b. Hypertension is the most common side effect when systemic analgesia is used. c. Analgesia and anesthesia perform the same function when it comes to blocking pain. d. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn.

d. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? a. Neonatal depression is possible. b. Fetal hypersensitivity to anesthetic is possible. c. The client is less sensitive to inhalation anesthetics. d. The client is more sensitive to preanesthetic medications.

a. Neonatal depression is possible.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? a. Sit on the edge of the bed with her feet dangling before ambulating. b. Remain in bed for at least 30 minutes. c. Ambulate only with assistance from the nurse or caregiver. d. Ambulate within 15 minutes to prevent spinal headache.

c. Ambulate only with assistance from the nurse or caregiver.

A client has just received combined spinal epidural. Which nursing assessment should be performed first? a. Assess vital signs. b. Assess pain level using a pain scale. c. Assess for progress in labor. d. Assess for fetal tachycardia. e. Assess for spontaneous rupture of membranes.

a. Assess vital signs.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: a. baseline variability. b. baseline FHR. c. short-term variability. d. fetal bradycardia.

b. baseline FHR.

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used. a. +4 station b. 0 station c. -4 station d. -2 station e. +2 station

c, d, b, e, a

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid? a. naloxone b. hydroxyzine c. midazolam d. nalbuphine

a. naloxone

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? a. Elevate her hips to prevent cord prolapse. b. Ask her to bear down with the next contraction. c. Assess fetal heart rate for fetal safety. d. Test a sample of amniotic fluid for protein.

c. Assess fetal heart rate for fetal safety.

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? a. Fetal status b. Risk factors c. Maternal status d. Maternal obstetrical history

a. Fetal status

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: a. "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening." b. "Effleurage is the effect of a full bladder on fetal descent." c. "Effleurage is light abdominal massage used to displace pain." d. "Effleurage is the pattern for cleaning the perineum before birth."

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

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? a. Notify the primary care provider. b. Increase her IV fluids. c. Change the position of the client. d. Administer oxygen.

c. Change the position of the client.

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique? a "Inhale through your nose and exhale through pursed lips." b. "Forcefully exhale every so often after inhaling and exhaling through your mouth." c. "Take a cleansing breath before but not after each contraction." d. "Inhale and exhale through your mouth about 4 times in 5 seconds."

a "Inhale through your nose and exhale through pursed lips."

A client has had a normal labor progression after the spontaneous rupture of clear fluid at home. As the client continues to show no signs of complications, which actions should the nurse prioritize to prepare for the birth? Select all that apply. a. Check the functionality of the oxygen source and equipment. b. Connect the meconium aspirator to the wall suction and turn it on. c. Document events as they are happening. d. Move the newborn warmer to the birth area and turn it on. e. Open the newborn crash cart or box to ensure easy access to all supplies.

a, c, d

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? a. "It distracts your brain from the sensations of pain." b. "It causes the release of endorphins." c. "It blocks the transmission of nerve messages of pain at the receptors." d. "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

a. "It distracts your brain from the sensations of pain."

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? a. 110-160 bpm b. 90-140 bpm c. 100-150 bpm d. 120-170 bpm

a. 110-160 bpm

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? a. Assess fetal heart rate. b. Assess for constipation. c. Assess for dry mouth. d. Assess maternal blood pressure.

a. Assess fetal heart rate.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? a. Clear to straw-colored fluid b. Cloudy white fluid c. Greenish fluid d. Bloody fluid

a. Clear to straw-colored fluid

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call? a. Shoulder dystocia b. Cephalopelvic disproportion c. Nuchal cord d. Fetal macrosomia

a. Shoulder dystocia

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? a. encouraging the woman to push when she has a strong desire to do so b. palpating the woman's fundus for position and firmness c. alleviating perineal discomfort with the application of ice packs d. completing the identification process of the newborn with the mother

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

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a. fetal heart rate declining late with contractions and remaining depressed b. fetal baseline rate increasing at least 5 mm Hg with contractions c. a shallow deceleration occurring with the beginning of contractions d. variable decelerations, too unpredictable to count

a. fetal heart rate declining late with contractions and remaining depressed

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks? a. ischial spine b. ischial tuberosity c. pubic symphysis d. cervical os

a. ischial spine

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? a. maternal hypotension and fetal bradycardia b. maternal hypertension and fetal tachycardia c. maternal hypotension and fetal tachycardia d. maternal hypertension and fetal bradycardia

a. maternal hypotension and fetal bradycardia

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? SATA a. change in temperature b. frequency of contractions c. uterine resting tone d. change in blood pressure e. intensity of contractions

b, c, e

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? a. "If you end up having a cesarean, the epidural can be used for anesthesia during surgery." b. "You have no trouble walking around and using the bathroom after you receive the epidural." c. "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." d. "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it."

b. "You have no trouble walking around and using the bathroom after you receive the epidural."

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's PRIORITY? a. signs of infection b. FHR c. fetal position d. maternal comfort level

b. FHR

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? a. FHR fluctuation range is undetectable. b. FHR fluctuates from 6 to 25 beats per minute. c. FHR fluctuates less than 5 beats per minute. d. FHR fluctuates over 25 beats per minute.

b. FHR fluctuates from 6 to 25 beats per minute.

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? a. Irregular contractions b. Meconium in the fluid c. Possible maternal infection d. Fetal heart rate

b. Meconium in the fluid

The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time? a. Activity Intolerance b. Risk for Injury c. Acute Pain d. Disturbed Sleep Pattern

b. Risk for Injury

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point? a. conscious relaxation/guided imagery in low Fowler position b. counterpressure against the sacrum c. effleurage of the abdomen during the contraction d. pant-blow (breaths and puffs breathing techniques)

b. counterpressure against the sacrum

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring? a. relaxin b. endorphins c. progesterone d. prostaglandins

b. endorphins

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. All options must be used. a. confirm presentation b. determine position c. determine presentation d. determine altitude

c, b, a, d

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. 6.5 d. 6.0

c. 6.5

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? a. Intense pain b. Staggering gait c. Difficulty breathing d. Decreased level of consciousness

c. Difficulty breathing

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: a. RUQ b. LUQ c. LLQ d. RLQ

c. LLQ

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse PRIORITIZE and report immediately for intervention? a. Dark red lochia b. Placental separation 15 minutes after birth c. Maternal tachycardia and falling blood pressure d. The mother is unable to void after 4 hours.

c. Maternal tachycardia and falling blood pressure

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor? a. Diffuse abdominal pain signals a complication with progression of labor. b. Pain is focal in nature. c. Pain originates from the cervix and lower uterine segment. d. It is reported as the worst pain a woman will ever feel.

c. Pain originates from the cervix and lower uterine segment.

The client may spend the latent phase of the first stage of labor at home unless which occurs? a. The contractions vary in length and intensity b. The client begins back labor c. The client experiences a rupture of membranes d. The client passes the bloody show

c. The client experiences a rupture of membranes

The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process? a. early-stage labor b. before dilation (dilatation) only c. just before birth d. just after birth

c. just before birth

A nurse is monitoring a female client with an epidural block. Which complication would be the MOST important for the nurse to monitor in the client? a. accidental intrathecal block b. a failed block c. respiratory depression d. postdural puncture (spinal) headache

c. respiratory depression

When counseling a couple for the upcoming birth of their child about pain relief, the nurse would incorporate what information in the teaching about measures to decrease the requests for pain medication?

continuous support through the labor process helps decrease the need for pain medication

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? a. Increase in variability by 27 bpm b. Decrease in variability for 15 seconds c. Deceleration followed by acceleration of 15 bpm d. Acceleration of at least 15 bpm for 15 seconds

d. Acceleration of at least 15 bpm for 15 seconds

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? a. Instruct the client to do slow-paced breathing. b. Assist the client in ambulating to the bathroom. c. Prepare the client for an epidural. d. Assess for labor progression.

d. Assess for labor progression.

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? a. Rupture of amniotic membranes b. Bloody show c. Engagement of fetus d. Dilation (dilatation) of cervix

d. Dilation (dilatation) of cervix

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? a. This would cause fetal depression in utero. b. The effects would wear off before birth. c. This can lead to maternal hypertension. d. This may prolong labor and increase complications.

d. This may prolong labor and increase complications.

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. Administer oxygen at 3 to 4 L by nasal cannula. c. Ask her to pant with the next contraction. d. Turn her or ask her to turn to her side.

d. Turn her or ask her to turn to her side.

The nurse has been monitoring the progression of labor for a primipara. At which time is the nurse most correct to prepare for delivery? a. When the client begins pushing b. When full dilation (dilatation) is reached c. When the health care provider arrives d. When the fetus is crowning

d. When the fetus is crowning

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? a. every 10 minutes b. every 20 minutes c. every 5 minutes d. every 15 minutes

d. every 15 minutes

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? a. increased feelings of control b. decreased sedation c. increased cervical dilation (dilatation) d. less anxiety

d. less anxiety

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. early decelerations b. accelerations c. variable decelerations d. prolonged decelerations

d. prolonged decelerations

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? a. maintaining the client in a supine position b. administrating IV naloxone c. administrating IV ephedrine d. starting an IV and hanging IV fluids

d. starting an IV and hanging IV fluids

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed?

determining the position of the fetus, the lie of the fetus, and the presentation of the fetus