CH14

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?

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

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition?

Diabetes

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?

Fetal status

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Meconium in the fluid Green tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions is expected at this stage of labor.

The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best?

Pain medication can affect the baby's breathing; let's try to focus and breathe."

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 1, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

Reflexes

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

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? Select all that apply.

Administer oxygen by mask. Turn the client on her left side. Assess client for underlying causes.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation.

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

Immediate surgery

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?

Placing a wedge under the hips

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? 1. Emotions are calm and happy. 2. Frequency of contractions are 5 to 6 minutes. 3. Fetus is at -1 station. 4. The urge to push occurs.

The urge to push occurs. Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. It would be most appropriate to meet which criterion?

rupture of membranes

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? 1. Effleurage 2. Massage 3. Pain pathway blockage 4. Abdominal imagery

1. Effleurage Explanation: a form of touch that involves light circular fingertip movements on the abdomen, is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? 1. Palpate the mother's radial pulse at the same time. 2. Ask the woman to hold her breath while assessing the FHR. 3. Have the woman lie completely flat on her back while auscultating. 4. Instruct the woman to bend her knees and flex her hips.

1. Palpate the mother's radial pulse at the same time.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? 1. encouraging the woman to ambulate 2. urging her to focus on one contraction at a time 3. having the client breathe with contractions 4. providing one-to-one support

1. encouraging the woman to ambulate

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? 1. prolonged decelerations 2. variable decelerations 3. early decelerations 4. accelerations

1. prolonged decelerations

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? 1. 10:05 a.m. 2. 10:30 a.m. 3. 11:15 a.m. 4. 11:30 a.m.

2. 10:30 a.m.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? 1. Decreased anxiety will increase trust in the nurse. 2. Anxiety can slow down labor and decrease oxygen to the fetus. 3. Increased anxiety will increase the risk for needing anesthesia. 4. Anxiety will increase blood pressure, increasing risk with an epidural.

2. Anxiety can slow down labor and decrease oxygen to the fetus. Out of control anxiety can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and can have a negative impact on the fetus by decreasing the amount of oxygen reaching the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural or the need for anesthesia. Trust in the nurse is not determined by the amount of anxiety the client experiences.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? 1. tactile stimulation 2. administration of oxygen by mask 3. fetal scalp stimulation 4. application of vibroacoustic stimulation

2. administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation. pg 460

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? 1. fetal position 2. external electronic fetal monitoring 3. fetal blood pH 4. fetal oxygen saturation

2. external electronic fetal monitoring

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? 1. Greenish fluid 2. Cloudy white fluid 3. Clear to straw-colored fluid 4. Bloody fluid

3. Clear to straw-colored fluid

In the labor and delivery unit, which is the best way to prevent the spread of infection? 1. Use sterile gloving 2. Limit vaginal examinations 3. Complete hand hygiene 4. Provide clean gloves in the room

3. Complete hand hygiene

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? 1. Administering an opioid such as meperidine or fentanyl 2. Administering a sedative such as secobarbital or pentobarbital 3. Practicing effleurage on the abdomen 4. Immersing the client in warm

3. Practicing effleurage on the abdomen

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: 1. acupressure. 2. patterned breathing. 3. effleurage. 4. therapeutic touch.

3. effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? 1. passage of the drug to the fetus 2. excessive contractions of the uterus 3. headache following anesthesia 4. increased frequency of micturition

3.headache following anesthesia

At which time does the nurse anticipate that the woman will need the most pain relief measures? 1 . In the latent phase of the first stage of labor 2. At the beginning of the second stage of labor 3. During the transition phase of the first stage of labor 4. In the active phase of the first stage of labor

4. In the active phase of the first stage of labor

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. At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

As a woman enters the second stage of labor, which would the nurse expect to assess? 1. falling asleep from exhaustion 2. feelings of being frightened by the change in contractions 3. expressions of satisfaction with her labor progress 4. reports of feeling hungry and unsatisfied

Feelings of being frightened by the change in contractions Explanation:The nature of contractions changes so drastically to an urge to push that this can be frightening.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

Vaginal examination

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the lie of the fetus determining the weight of the fetus determining the position of the fetus determining the presentation of the fetus determining the size of the fetus

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency?

every 15 minutes It is recommended that the FHR be assessed during the second stage of labor every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

uterine resting tone frequency of contractions intensity of contractions

If the monitor pattern of uteroplacental insufficiency were present, which of the following would you do first? 1) Turn her or ask her to turn to her side. 2) Ask her to pant with the next contraction. 3) Administer oxygen at 3 to 4 L by nasal cannula. 4) Help the woman to sit up in a semi-Fowler's position.

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

Which statement is true regarding analgesia versus anesthesia? 1.Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. 2. Hypotension is the most common side effect when systemic analgesia is used. 3. Decreased FHR variability is a common side effect when regional anesthesia is used. 4. 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.

1. Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process? 1. Client priorities and preferences are incorporated into the plan. 2. The health care provider decides the best pain relief for the mother and family. 3. The client has the baby without any analgesic or anesthetic. 4. The nurse suggests alternative methods of pain relief.

1. Client priorities and preferences are incorporated into the plan.

The pain of labor is influenced by many factors. What is one of these factors? 1. The woman is prepared for labor and birth. 2. The woman has a high tolerance for pain. 3. The woman has a high threshold for pain. 4. The woman has lots of visitors during labor.

1. The woman is prepared for labor and birth. The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

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? 1. Bradypnea and hypertension 2. Tachypnea and a widening pulse pressure 3. Tachycardia and a falling blood pressure 4. Bradycardia and auscultation of fluid in the base of the lungs

3. Tachycardia and a falling blood pressure Explanation: Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; immediately report these signs.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? 1. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. 2. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain. 3. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. 4. Women report higher levels of satisfaction when regional anesthetics are used to control pain.

3. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience Explanation: Research has shown that women report higher levels of satisfaction with their labor experience when they feel a high degree of control over the experience of pain

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: 1. 7.25 or more 2. 7.21 3. 7.20 4. 7.15 or less

4. 7.15 or less.

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? 1. Sitting in a hot tub helps decrease the need for pain medication. 2. Lying on an ice pack can help decrease the need for pain medication. 3. A quick epidural can replace the need for pain medication. 4. Continuous support through the labor process helps decrease the need for pain medication.

4. Continuous support through the labor process helps decrease the need for pain medication. Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication. pg 465

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? 1. administrating IV ephedrine 2. administrating IV naloxone 3. maintaining the client in a supine position 4. starting an IV and hanging IV fluids

4. starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventative. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventative.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? 1. Explain to the client that narcotics should only be administered an hour or less before birth. 2. Agree with the client, and administer the drug immediately to keep the pain manageable. 3. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. 4. Refuse to administer narcotics because they can develop dependency in the client and the fetus.

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor Explanation:The timing of administration of narcotics in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?

Lab work will be drawn to rule out acid-base imbalances.

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?

Neonatal depression is possible.

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?

endorphins

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomenIn a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia