chap 6 Nursing Care of Mother and Infant During Labor and Birth
Which finding in the patient indicates is normal during postpartum.?
Vaginal blood containing small clots
fluctuations in the water seal of a chest tube.is known as
Tidalingp p. 143-145
sign of impending labor
Braxton Hicks contractions, increased vaginal discharge, and bloody show are always signs of impending labor
Which presentation involves a partial extension of the fetal head due to the bending of the fetal neck and head?
Brow presentation This presentation results from poor flexion of the head; therefore, it tends to convert to either a face or a vertex presentation. p 123
What are the neurological changes that occur during labor?
Several neurological changes, such as amnesia, self-centeredness, and endorphin release, occur during labor. Amnesia occurs during the second stage of labor. During labor, euphoria changes to self-centeredness as the labor progresses. Endorphin release occurs during labor and produces natural and general sedation.
U-shaped pattern V-shaped pattern W-shaped pattern
U-, V-, and W-shaped patterns are caused by variable decelerations in the patient's heart rate. These indicate the compression of the umbilical cord, resulting in respiratory acidosis. p. 136
What are the causes of fetal bradycardia? Fetal hypoxia Maternal hypoglycemia Umbilical cord compression
A fetal heart rate below 110 beats/minute for 10 minutes or longer leads to fetal bradycardia. Fetal hypoxia, maternal hypoglycemia, and umbilical cord compression cause fetal bradycardia. Fetal hypoxia decreases the heart rate due to decreased oxygen supply to the fetus. Maternal hypoglycemia is also one of the causes of fetal bradycardia, because the glucose level affects the fetal heart rate. Compression of the umbilical cord results in respiratory distress in the fetus because of the nuchal cord compression, resulting in fetal bradycardia.
The nurse finds that, 15 minutes after birth, the heart rate of an infant is 100 beats per minute, and the infant has a flexed body posture with minimal response to stimulation. The nurse also finds that the infant has a slow weak cry, with a pink body and blue extremities. What will be the Apgar score of the infant? Record your answer using a whole number
7 The Apgar score is used to assess the condition of the infant and accordingly plan the interventions needed. The Apgar score for 100 beats per minute is 2; flexed body posture is 2; minimal response to stimulation is 1; slow, weak cry is 1; pink body with blue extremities is 1. By adding all the scores, the Apgar score of the infant will be 7.
Which finding in the patient indicates a vaginal laceration?
A continuous trickle of bright red vaginal bleeding no more than 1 pad should be saturated in an hour and the women should not pass large clots.
What are the causes of fetal bradycardia? Fetal hypoxia Maternal hypoglycemia Umbilical cord compression
A fetal heart rate below 110 beats/minute for 10 minutes or longer leads to fetal bradycardia. Fetal hypoxia, maternal hypoglycemia, and umbilical cord compression cause fetal bradycardia. Fetal hypoxia decreases the heart rate due to decreased oxygen supply to the fetus. Maternal hypoglycemia is also one of the causes of fetal bradycardia, because the glucose level affects the fetal heart rate. Compression of the umbilical cord results in respiratory distress in the fetus because of the nuchal cord compression, resulting in fetal bradycardia. p133
The nurse finds that the fetal heart rate in a pregnant patient varies by 15 beats/min below the baseline, and the effect lasts even after the contraction ends. What would be the best intervention provided to the patient in this condition? Administer oxygen 8 to 10 L/min through a face mask.
A fetal heart rate of 15 beats/min below the baseline that lasts even after the contraction ends indicates that the fetus has late decelerations. Maternal oxygenation is the first intervention taken to reduce the risk of fetal hypoxia caused by late deceleration. Therefore, the nurse should administer oxygen at 8 to 10 L/min through a face mask .p 137
What is the reason for the occurrence of fetal tachysystole?
A fetal heart rate that is greater than 160 beats/min and lasts for 2 to 10 minutes or longer is called fetal tachysystole. It can be caused by maternal dehydration or fever
When is a nitrazine test performed?
A nitrazine test is performed to determine whether amniotic fluid is present in the vaginal outflow. The nitrazine test is performed if it is unclear whether the mother's membranes are ruptured. p. 137
nulliparous
A patient who has not given birth previously is nulliparous and will likely have engagement prior to labor. Therefore, the patient may not require cesarean delivery. If the multiparous patient had a previous cesarean delivery, then the angle of progression would not be affected and the patient would likely have engagement before labor. p. 126
A patient in the third trimester of pregnancy reports a sudden outflow of fluid from the vagina. While collecting the data, the nurse finds that the color of the secretion is green. What does it indicate? The fetus has respiratory depression.
A sudden outflow of fluid from the vagina during the third trimester of pregnancy indicates a rupture of the amniotic membranes. Green coloration of the amniotic fluid indicates that the fetus has eliminated the first stool before birth. This is associated with the complication of respiratory depression in the fetus.
Which is the first factor evaluated in an infant within the first 5 minutes of birth?
According to the Apgar score, vital signs such as heart rate and respiratory rate should measured within 5 minutes of the birth. The heart rate is the first parameter that needs to be measured in the infant within 5 minutes of birth. Respiratory rate is the second parameter that should be measured after the child's birth. The grasping reflex of the infant should be measured after checking the vital signs. Infant skin color should be assessed after assessing all other parameters.
Which is the first factor evaluated in an infant within the first 5 minutes of birth? Heart rate
According to the Apgar score, vital signs such as heart rate and respiratory rate should measured within 5 minutes of the birth. The heart rate is the first parameter that needs to be measured in the infant within 5 minutes of birth. Respiratory rate is the second parameter that should be measured after the child's birth. The grasping reflex of the infant should be measured after checking the vital signs. Infant skin color should be assessed after assessing all other parameters.
While caring for a postpartum patient, the nurse observes that the infant has a weak cry, a completely pink body, and minimal flexion of the extremities. The infant's heart rate at 10 minutes after birth is < 100 beats per minute, and the infant has minimal response to stimulation. Which nursing intervention should the nurse be instructed to perform in this situation? Gently rub the back of the infant.
According to the findings in the infant, the Apgar score of the infant will be 6. An Apgar score of 4 to 7 indicates that the infant is having slight respiratory depression and needs gentle stimulation on the back of the body. Hence, the nurse should gently rub the back of the infant to stimulate proper respiration in the infant. Active resuscitation is needed in an infant whose Apgar score is less than 3
While caring for a postpartum patient, the nurse observes that the infant has a weak cry, a completely pink body, and minimal flexion of the extremities. The infant's heart rate at 10 minutes after birth is < 100 beats per minute, and the infant has minimal response to stimulation. Which nursing intervention should the nurse be instructed to perform in this situation? Gently rub the back of the infant.
According to the findings in the infant, the Apgar score of the infant will be 6. An Apgar score of 4 to 7 indicates that the infant is having slight respiratory depression and needs gentle stimulation on the back of the body. Hence, the nurse should gently rub the back of the infant to stimulate proper respiration in the infant. Active resuscitation is needed in an infant whose Apgar score is less than 3. p 152
What would be the color of the infant's body if the Apgar score is 0?
An Apgar score of 0 indicates that the infant has a blue or pale pink color due to acrocyanosis.
What would be the color of the infant's body if the Apgar score is 1?
An Apgar score of 1 indicates that the infant has a pink body.
The nurse is assisting a patient during labor. Which nursing interventions would prevent maternal exhaustion and inhibition of labor? Providing emotional support to the patient Preventing the patient from premature pushing
Anxiety or fear during labor inhibits the process of labor; therefore, the nurse should provide emotional support to relieve the patient's fear. Premature pushing refers to maternal efforts to push the baby down the birth canal before the cervix is completely dilated. This may be due to the fetus pushing against the rectum. Premature pushing causes exhaustion and fatigue and should be prevented. The patient should void as much as possible prior to labor because this helps ease labor. p122
What are the musculosketal changes that occur during labor?
Backache is not a neurological change. Backache is a musculoskeletal change that occurs due to increased joint laxity. muscle activity increases during labor p 140
What is the purpose of the administration of vitamin K (AquaMephyton) to a newborn?
Blood clotting Vitamin K (AquaMephyton) is required by the newborn to assist in blood clotting. A newborn lacks vitamin K at birth because of a sterile gastrointestinal tract. Newborns receive a single dose of vitamin K into the vastus lateralis muscle before leaving the delivery room, usually at age 1 hour. p 153
Which hematological changes occur during labor? Loss of blood, Increased fetal hemoglobin
Blood loss of about 500 mL may occur during delivery. Increased fetal hemoglobin helps the fetus carry an increased amount of oxygen during labor. Fibrinogen levels increase during pregnancy to prevent hemorrhage during labor. Blood volume decreases during labor due to blood loss. During labor, clotting factors increase to prevent hemorrhage. p. 141
signs of impending labor
Braxton Hicks contractions (increasing in intensity)or false labor; bloody show, increased vaginal discharge, rupture of the membranes.
Braxton Hicks contractions
Braxton Hicks contractions are irregular contractions of the uterus, which stop or decrease on ambulation.
The nurse is caring for a patient in the 36th week of gestation. The nurse finds that the patient has intense Braxton Hicks contractions along with continuous clear, thick, pink vaginal discharge. The patient also has a slight weight loss of about 2 lbs. What does the nurse infer from this information? The patient is at term.
Braxton Hicks contractions are irregular contractions, which are also called false labor; they intensify as the term of delivery approaches. Clear, thick, pink vaginal discharge is called bloody show, which is seen due to intercourse and during the onset of delivery. Intense Braxton Hicks contractions coupled with pink vaginal discharge do not indicate false labor. Uterine prolapse generally occurs in patients after a vaginal delivery. Itching and irritation along with vaginal discharge indicate vaginal infection. A clear, thick, pink vaginal discharge does not indicate a vaginal infection.
swelling of the scalp in a newborn is known as
Caput succedaneum p. 143-145
The nurse is caring for a patient during the active phase of labor. Which characteristic does the nurse expect in the patient during this phase?
Cervix dilation of 4-7 cm The labor process is classified into two stages. The first stage is dilation and effacement and second stage is expulsion of the fetus. The first stage again includes three phases: the latent phase, the active phase, and the transition phase. The active phase of labor is characterized by cervical dilation of about 4 to 7 cm. The amniotic membranes are intact during the latent phase of labor. During the transition phase, firm contractions occur for a duration of 60-90 seconds. p. 144
The nurse is caring for a japanese newborn. Which cultural practice does the nurse observe?
Chanting and throwing rice to ward off evil spirits
The nurse is assisting the primary health care provider during an amniotomy in a patient. The nurse finds that the amniotic fluid of the patient has white flecks. What would be the probable reason for this finding in the patient? Vernix in the amniotic fluid
Clear amniotic fluid with white flecks is a normal finding. The white flecks in the amniotic fluid are present due to the occurrence of vernix, a skin protectant on the fetus. Yellow-colored amniotic fluid and an offensive odor indicate infection in the patient. Meconium is the first stool of the fetus. If the fetus is in respiratory distress, then it passes meconium in the womb. Green-stained fluid indicates that the fetus has passed meconium. Compression of the umbilical cord also causes decreased respiratory status in the fetus. p. 137
The nurse is assisting a primary health care provider during the labor of a patient. The nurse finds that the patient has uterine contractions that last for more than 90 seconds for every 2 minutes. The fundus of the patient's uterus feels similar to the chin. What does the nurse infer from this information?
Contractions that last longer than 90 seconds and are at intervals of 2 minutes would reduce the oxygen supply to the fetus. This can result in fetal hypoxia. If the fundus of the uterus feels similar to the chin, then the patient is having moderate contractions.
The nurse is assisting a primary health care provider during the labor of a patient. The nurse finds that the patient has uterine contractions that last for more than 90 seconds for every 2 minutes. The fundus of the patient's uterus feels similar to the tip of the nose. What does the nurse infer from this information?
Contractions that last longer than 90 seconds and are at intervals of 2 minutes would reduce the oxygen supply to the fetus. This can result in fetal hypoxia. If the fundus of the uterus feels similar to the tip of the nose, mild contractions are occurring.
The nurse is assisting a primary health care provider during the labor of a patient. The nurse finds that the patient has uterine contractions that last for more than 90 seconds for every 2 minutes. The fundus of the patient's uterus feels similar to the forehead. What does the nurse infer from this information?
Contractions that last longer than 90 seconds and are at intervals of 2 minutes would reduce the oxygen supply to the fetus. This can result in fetal hypoxia. if fundus firm only if the uterus feels similar to the forehead. Longer contractions may cause fetal hypoxia, the fundus cannot be indented with the fingertips firm contractions are occuring p 120-121
cord prolapse
Cord prolapse causes marked variability of more than 25 beats per minute.
what is one of the most important sutures in a newborn's skull.
Coronal presentation p. 143-145
measurement of cervix dilation
Dilation and effacement occur during the first stage of labor. The process is divided into three phases. The transition phase is the third phase of the first stage. During the transition phase of labor, the cervix will dilate from 7 to 10 centimeters. During the active phase of labor, the dilation of cervix will be 4 to 7 centimeters. Dilation of the cervix between 5 and 6 centimeters also indicates the active phase of labor. During the latent phase of labor, the patient undergoes cervical dilation of 1 to 4 centimeters. p. 144
Which measurement of cervix dilation indicates the transition phase of labor? 7 to 10 centimeters
Dilation and effacement occur during the first stage of labor. The process is divided into three phases. The transition phase is the third phase of the first stage. During the transition phase of labor, the cervix will dilate from 7 to 10 centimeters. During the active phase of labor, the dilation of cervix will be 4 to 7 centimeters. Dilation of the cervix between 5 and 6 centimeters also indicates the active phase of labor. During the latent phase of labor, the patient undergoes cervical dilation of 1 to 4 centimeters. p. 144
What would the nurse document as an expected assessment finding of the fundus of the uterus during the fourth stage of labor? Firm and at the umbilicus Firm and deviated to the right Soft to touch but firm with massage
During the fourth stage, recovery of labor, the uterus is normally found firmly contracted at or below the umbilicus level. Deviation to the right can indicate a full bladder. A boggy or soft uterus can indicate a potential complication. p. 145
What would the nurse document as an expected assessment finding of the fundus of the uterus during the fourth stage of labor? Firm and at the umbilicus
During the fourth stage, recovery of labor, the uterus is normally found firmly contracted at or below the umbilicus level. Deviation to the right can indicate a full bladder. A boggy or soft uterus can indicate a potential complication. The uterus is not usually found deviated to the left. p. 145
What is the reason for the occurrence of fetal hypoxia?
Fetal hypoxia causes absent variability.
Which findings enabled the nurse to conclude the risk of fetal tachysystole?
Fetal tachysystole is a baseline fetal heart rate greater than 160 beats/minute that lasts for 10 minutes due to maternal fever or maternal dehydration.. p134
The nurse is caring for a woman at 36 weeks of gestation. The nurse finds that the patient has frequent intense contractions while walking, along with bloody show and discomfort in the lower abdomen. What does the nurse infer from these findings?
Frequent intense contractions that increase with walking, along with the presence of bloody show and discomfort in the lower abdomen indicate that the patient is experiencing labor pain.
The nursing instructor is educating nursing students about labor and childbirth. Which signs, according to the nursing instructor, indicate impending birth in the patient?
Grunting sounds made by the patient and bulging of the perineum due to the descent of the fetus indicate that the patient is about to give birth. p 129
The nursing instructor is educating nursing students about labor and childbirth. Which signs, according to the nursing instructor, indicate impending birth in the patient? Grunting sounds by the patient Bulging of the patient's perineum
Grunting sounds made by the patient and bulging of the perineum due to the descent of the fetus indicate that the patient is about to give birth. p129
Which nursing action has the highest priority for a patient in the second stage of labor?
Help the mother push effectively The second stage of labor is the pushing stage. The nurse should help the mother push effectively. The mother cannot breastfeed in the second stage of labor Pain medication should not be administered in the second stage because it will cause a lethargic neonate and possibly depress the newborn's respirations. pp. 144-145
What is the advantage of delivering at home?
If delivering at home, the patient would have no risk of acquiring pathogens from other patients. In addition, a home setting allows the presence of the entire family during labor. Because the patient will have familiar faces in the home setting, her anxiety may be reduced. Many families prefer to undergo less or no strenuous scientific procedures for delivery. A home setting for labor allows a low-technology birth. p 116
Meconium is the first stool of the fetus.
If the fetus is in respiratory distress, then it passes meconium in the womb. Green-stained fluid indicates that the fetus has passed meconium. Compression of the umbilical cord also causes decreased respiratory status in the fetus. Green amniotic fluid indicates that the fetus has passed the first stool, called meconium, before the labor
The nurse is caring for a pakistanian newborn. Which cultural practice does the nurse observe?
In Muslim culture as practiced in Pakistan, the father shaves the head of the newborn pp. 117, 118
The nurse is repeating instructions to a patient about the conditions that need immediate medical attention.
Intense contractions for every 5 minutes for 1 hour indicate labor pain, so the patient should report to the health care facility immediately. A decrease in fetal movements is seen prior to labor and it is also a sign of fetal compromise or fetal demise. A sudden outflow from the vagina is caused by ruptured membranes; it indicates the onset of delivery and may also cause an emergency. pp. 126, 128
What Apgar score indicates that an infant should undergo active resuscitation? 2
The Apgar score is used to evaluate the infant's condition after birth. An Apgar score < 3 indicates that the infant needs active resuscitation. A score of 8 to 10 means that the infant requires only continued observation and support of adaptation. Hence, the score of 9 indicates that the infant is in a good condition. A score of 4 to 7 indicates that the infant needs gentle stimulation such as rubbing of the back. These scores do not indicate the need for immediate active resuscitation. p. 152
What would be the color of the infant's body if the Apgar score is 2?
The Apgar score is used to evaluate the infant's condition after birth. Complete pink color of the infant's body should be given an Apgar score of 2. p. 152
The nurse is assisting the primary health care provider while determining the fetal presentation by Leopold's maneuver. How does the nurse expect the primary health care provider to confirm the presentation of the fetus? By palpating the suprapubic area of the patient
Leopold's maneuver is the technique used to determine the fetal position and presentation. Palpation of the suprapubic area of the patient enables the primary health care provider to determine the presentation of the fetal head. This helps to confirm the fetal presentation. Palpation of the uterine fundus gives an idea of fetal presence, but it does not confirm the presentation of the fetus. Palpating a hard, smooth contour helps to locate the back of the fetus. By palpating the maternal abdomen toward the feet or the symphysis pubis, the nurse can determine the attitude of the fetal head.
The ultrasound scan of a patient shows that the fetus is parallel to the mother's spine. The fetal head is fully flexed in the transverse position towards the left side. How is this information represented in the report?
Longitudinal lie; vertex presentation LOT The fetus is parallel to the mother's spine; therefore, it is a longitudinal lie. Complete flexion of the fetal head represents the vertex position. If the fetus is in vertex position, it is represented as occiput. Transverse position toward the left is represented as LOT If the fetus is at right angles to the mother's body with the feet flexed facing anteriorly, it would be represented as transverse lie, breech presentation LST. If the fetus is at a right angle with the vertex anterior, then it would be represented as transverse lie, vertex presentation LOA. If the fetus is parallel to the body with legs flexed toward the left, it would be represented as longitudinal lie, breech presentation LSA. pp. 122, 125, 133
While caring for a newborn, the nurse finds that the newborn's had hypoglycemia and cold stress. What could be the reason for this finding?
Low body temperature can cause hypoglycemia and cold stress. Cold stress leads to rapid respiration and increased oxygen consumption. p. 151
Which nursing interventions help to maintain a neutral thermal environment for the newborn? .
Maintaining a neutral thermal environment is a critical factor in caring for a newborn. Drying the infant with a towel prevents heat loss caused by evaporation of the amniotic fluid on the skin. A radiant warmer helps supply heat to the infant. If the moist head is left open to room air, heat loss can occur. Hence, a hat should be placed on the head of the infant. The infant should be wrapped in warm blankets and not left exposed to the open air. Skin-to-skin contact of the mother and the infant should not be avoided, as it can prevent heat loss and enhance the bonding of the infant with the mother. p. 150
Which nursing interventions help to maintain a neutral thermal environment for the newborn? . Dry the infant with a warm towel. Place the infant in a radiant warmer. Place a hat on the head of the infant.
Maintaining a neutral thermal environment is a critical factor in caring for a newborn. Drying the infant with a towel prevents heat loss caused by evaporation of the amniotic fluid on the skin. A radiant warmer helps supply heat to the infant. If the moist head is left open to room air, heat loss can occur. Hence, a hat should be placed on the head of the infant. The infant should be wrapped in warm blankets and not left exposed to the open air. Skin-to-skin contact of the mother and the infant should not be avoided, as it can prevent heat loss and enhance the bonding of the infant with the mother. p. 150
Which cultural practice would the nurse find while caring for a Hindu patient?
Patients who follow Hinduism will be obedient and remain passive during delivery. The patient will follow the instructions of the primary health care provider. Many Hindu patients remain secluded for 40 days after delivery, as they feel it would be unlucky for the baby to do otherwise. A Hindu patient would breastfeed rather than bottle feed the infant. Cultural beliefs prevent Hindu women from taking a shower postpartum; they prefer to take sponge baths. There is no cultural practice that would prevent a Hindu woman from asking for pain relief. p. 118
The nurse is caring for a Falkland Islands patient during the immediate postpartum period. Which cultural practice does the nurse observe in the patient?
Placing keys and combs under the pillow
The nurse is assisting a patient in labor. The nurse finds that the fetus is presented in the frank breech position. Which finding enabled the nurse to make such a conclusion?
Presence of the buttocks of the fetus at the cervix
While caring for a newborn, the nurse finds that the newborn's areas other than the hands and the feet of the infant.. What could be the reason for this finding?
Respiratory distress causes persistent cyanosis, which is seen in areas other than the hands and the feet of the infant.
While caring for a newborn, the nurse finds that the newborn's hands and feet are blue. What could be the reason for this finding?
Sluggish peripheral circulation Bluish discoloration of the extremities in infants is known as acrocyanosis. This is normal in infants and is caused by sluggish peripheral circulation.
The nurse is caring for a patient in labor who has been administered meperidine hydrochloride (Demerol) during labor. On reviewing the laboratory reports of the patient, the nurse finds that the fetus is anemic. Which pattern of heart rate does the nurse expect on the electronic fetal heart rate monitor?
Smooth wave pattern The sinusoidal pattern is a specific fetal heart rate pattern that has a smooth, wavelike appearance or undulating pattern. This is caused by the fetal response to medications such as meperidine hydrochloride (Demerol), provided to the mother during labor. This pattern is also observed due to fetal anemia p 136 Fetal response to meperidine hydrochloride (Demerol) shows a specific pattern of the fetal heart rate known as a sinusoidal pattern.
What signs of respiratory distress in the neonate should be reported immediately?
Some signs of respiratory distress that should be immediately reported include grunting respirations, persistent cyanosis (other than of the hands and feet), flaring of the nostrils, retractions, sustained respiratory rate higher than 60 breaths/min, and sustained heart rate greater than 160 beats/min or less than 110 beats/min. pp. 150-151
When is specific eye care given to an infant?
Specific eye care is given to infants to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. This is administered 1 hour after birth, so that the mother and the infant can bond in the first hour It is recommended to provide eye care 1 hour after birth rather than immediately after birth to facilitate bonding between the infant and mother. p. 152
At what point during the labor process does the health care provider know that the second stage of labor has begun? The cervix is fully dilated at 10 cm.
Stage 2 is from full dilation of the cervix until birth of the fetus. Pushing before full dilation can be dangerous to the fetus and exhausting to the mother. The +1 station is too high. Delivery of the placenta is stage 3. p144-145
What would be the color of the infant's body if the Apgar score is 2? Complete pink color
The Apgar score is used to evaluate the infant's condition after birth. Complete pink color of the infant's body should be given an Apgar score of 2. An Apgar score of 1 indicates that the infant has a pink body. An Apgar score of 0 indicates that the infant has a blue or pale pink color due to acrocyanosis. p. 152
What is the usual duration of the active phase of labor?
The active phase is the second phase of the first stage of labor. Duration of the active phase of the labor is about 2 to 6 hours. Duration of the latent phase of labor is about 4 to 6 hours. The active phase of labor is generally not completed within 30 minutes to 1 hour. The third phase of labor lasts for 5-30 min and ends with the expulsion of placenta. The second stage of labor typically lasts for about 30 minutes to 2 hours. p. 144
At what point during the labor process does the health care provider know that the second stage of labor has begun?
The cervix is fully dilated at 10 cm. Stage 2 is from full dilation of the cervix until birth of the fetus.
The nurse is caring for a Chinese newborn. Which cultural practice does the nurse observe?
The father brings a silk material called hada. In Chinese culture, the father brings a long piece of silk material called hada as a sign of greeting and good luck to the child p 117-120
The nurse is reviewing the laboratory reports of the patient who is undergoing labor. Which findings enabled the nurse to conclude the risk of fetal tachysystole?
The fetal heart rate is 165 beats/min for 10 min in the third trimester p. 134
The ultrasound scan of a patient shows that the fetus is parallel to the mother's spine. The fetal head is fully flexed in the transverse position towards the left side. How is this information represented in the report? Longitudinal lie; vertex presentation LOT
The fetus is parallel to the mother's spine; therefore, it is a longitudinal lie. Complete flexion of the fetal head represents the vertex position. If the fetus is in vertex position, it is represented as occiput. Transverse position toward the left is represented as LOT. If the fetus is at right angles to the mother's body with the feet flexed facing anteriorly, it would be represented as transverse lie, breech presentation LST. If the fetus is at a right angle with the vertex anterior, then it would be represented as transverse lie, vertex presentation LOA. If the fetus is parallel to the body with legs flexed toward the left, it would be represented as longitudinal lie, breech presentation LSA. pp. 122, 125, 133
If the sacrum of the fetus in a breech presentation is in the mother's right posterior pelvis, it is described as: right sacrum posterior.
The first word refers to what side of the mom's pelvis the presenting part is facing, the second is the fetal reference point ( occiput for vertex presentations, mentum for face, and sacrum for breech), and the third references the front (anterior) or back (posterior) of the mother's pelvis. If the fetus is neither anterior nor posterior, then it is transverse.
If the sacrum of the fetus in a breech presentation is in the mother's right posterior pelvis, it is described as: right sacrum posterior.
The first word refers to what side of the mom's pelvis the presenting part is facing, the second is the fetal reference point ( occiput for vertex presentations, mentum for face, and sacrum for breech), and the third references the front (anterior) or back (posterior) of the mother's pelvis. If the fetus is neither anterior nor posterior, then it is transverse. p. 124-125
The nurse is assisting a patient in labor. The nurse finds that the fetus is presented in the frank breech position. Which finding enabled the nurse to make such a conclusion? Presence of the buttocks of the fetus at the cervix
The frank breech position is characterized by the presence of the buttocks of the fetus at the cervix. When both feet of the fetus are at the cervix, the fetus is in a footling breech position. If the fetus is in the left occiput anterior position, the fetus is in a vertex presentation. The right mentum anterior position is a face presentation, but not a fetal body presentation.
The nurse is instructed to collect the index fingerprint of the mother and footprints of the infant after labor. What is the rationale behind this intervention?
The index fingerprint of the mother and footprint of the infant are obtained after labor to identify the infant in case of abduction Preprinted wristband numbers help the mother to retrieve the infant from the nursery. p. 151
Which physiological changes occur in a patient during labor?
Uterine contractions release 400 mL of blood into the vascular system, resulting in an increase in cardiac output. Increased oxygen consumption is caused by the increased physical activity of labor Gastrointestinal motility decreases during labor. Progesterone levels increase during pregnancy and decrease during labor. During labor, the patient has increased physical activity, which utilizes blood glucose. Therefore, the blood glucose levels decrease. pp. 140, 141
The nurse is caring for a patient during the active phase of labor. Which characteristic does the nurse expect in the patient during this phase? Cervix dilation of 4-7 cm
The labor process is classified into two stages. The first stage is dilation and effacement and second stage is expulsion of the fetus. The first stage again includes three phases: the latent phase, the active phase, and the transition phase. The active phase of labor is characterized by cervical dilation of about 4 to 7 cm. The amniotic membranes are intact during the latent phase of labor. During the transition phase, firm contractions occur for a duration of 60-90 seconds. p144
While assisting a patient in labor, the nurse finds that the patient has passed stool and has a bulged perineum. The patient states, "The baby is coming." What does the nurse infer from these findings? The patient is in the second stage of labor.
The labor process is classified into two stages; the first stage involves the dilation and effacement of the cervix, and the second stage involves expulsion of the fetus. The first stage includes three phases: the latent phase, the active phase, and the transition phase. During the second stage of labor, the patient may state that the baby is coming. Bulging of the perineum occurs, and the patient may pass stool in this stage. This behavior is not seen in the first stage of labor. In the active phase of labor, facial flushing and fears of losing control are observed in the patient. In the latent phase of labor, increased urine frequency and increased thirst are observed. In the transition phase of labor, restlessness, tremors of the legs, and irritable behavior are observed in the patient. p. 144
During labor, a patient started pushing before the complete dilation of the cervix. What risks does the nurse expect in the patient due to this behavior?
The nurse must instruct the patient to avoid pushing before the cervix is fully dilated. Pushing before full dilation may cause fetal hypoxia and maternal exhaustion. p 142
the nurse observes that a patient is anxious. After interacting with her, the nurse finds that the patient had a cesarean section in her previous pregnancy and the patient fears having another cesarean. Which response by the nurse would be helpful to relieve the patient's anxiety?
The nurse should provide empathy and support to the patient who is anxious about having a cesarean for the second time. The nurse should advise the patient to remain calm to reduce the risks associated with labor. The nurse should not promise the patient that a cesarean may not be required this time, as the patient may require a cesarean if the patient has a risk of complications. The nurse should not tell the patient that feeling tense or worried may increase complications or risk of cesarean. This might make the patient feel depressed. p. 143
The nurse is caring for a Khmer patient during the immediate postpartum period. Which cultural practice does the nurse observe in the patient?
The patient discards the colostrum(first milk produce after birth) Khmer or Cambodian patients avoid feeding colostrum to the infant as a part of their cultural practice. Cambodian patients prefer only vegetables; they do not eat meat after labor.
Which physiological changes occur in a patient during labor? Increased cardiac output Increased oxygen consumption
Uterine contractions release 400 mL of blood into the vascular system, resulting in an increase in cardiac output. Increased oxygen consumption is caused by the increased physical activity of labor. Gastrointestinal motility decreases during labor. Progesterone levels increase during pregnancy and decrease during labor. During labor, the patient has increased physical activity, which utilizes blood glucose. Therefore, the blood glucose levels decrease. pp. 140, 141
What is the reason for the occurrence of Uteroplacental insufficiency?
Uteroplacental insufficiency causes absent variability. p 134
While assisting a patient during labor, the nurse finds that the fundus is not easily indented with the fingertips and is similar in feel to the forehead. What does the nurse infer from these findings?
The patient is having firm contractions. Based on their intensity, contractions can be classified as mild, moderate, or firm. During firm contractions, the fundus cannot be indented with the fingertips. The fundus of the uterus feels similar to the forehead during these contractions. During mild contractions, the fundus of the uterus does not distend and feels similar to the tip of the nose. In moderate contractions, the fundus can be indented with the fingertips with more difficulty, and the fundus of the uterus feels similar to the chin. Based on their strength, uterine contractions are classified into three phases: increment, peak, and decrement. However, these findings do not indicate decrement of contractions. pp. 120-121
The nurse is caring for a patient during labor. The nurse observes that the presenting part of the fetus has not reached 0 station as labor begins. What does the nurse infer from this observation?
The patient is multiparous and had vaginal delivery previously. A patient who has previously given birth is multiparous. The presenting part of the fetus is seen at 0 station (or the level of the ischial spines on the woman's pelvis) during engagement. Engagement is the process of fetal descent into the mother's pelvis. A multiparous patient who had a previous vaginal delivery will have a decrease in the angle between the symphysis pubis and the fetal head (angle of progression). Therefore, the process of engagement may not occur prior to labor.
A patient in the third trimester reports regular, intense contractions. The nurse finds that the cervix of the patient is dilated to 10 cm. What does the nurse infer from this finding? The cervix has completely effaced.
The patient will have regular intense contractions when she reaches term, which cause dilation of the cervix. Dilation of the cervix to 10 cm indicates complete cervical dilation or effacement.
The nurse is assisting a patient during labor. The nurse finds that the fetal head is in the left quadrant of the patient's pelvis facing the left thigh, and it is undergoing restitution. What does the nurse infer from these findings? The fetus is in the left occiput anterior position and the head is born in extension.
The presence of the fetal head in the left quadrant of the patient's pelvis facing the left thigh indicates the left occiput anterior position. Restitution is the phenomenon involving the realignment of the head according to the shoulders when born in extension. From these findings, the nurse can infer that the fetus is presenting in left occiput anterior position and the head is born in extension. A head born in flexion does not require restitution. In the left occiput posterior position, the fetal head will be facing the right thigh. pp. 124-125, 128
The nurse is assisting a patient during labor. The nurse finds that the fetal head is in the left quadrant of the patient's pelvis facing the left thigh, and it is undergoing restitution. What does the nurse infer from these findings? The fetus is in the left occiput anterior position and the head is born in flexion. The fetus is in the left occiput posterior position and the head is born in flexion. The fetus is in the left occiput anterior position and the head is born in extension. The fetus is in the left occiput posterior position and the head is born in extension.
The presence of the fetal head in the left quadrant of the patient's pelvis facing the left thigh indicates the left occiput anterior position. Restitution is the phenomenon involving the realignment of the head according to the shoulders when born in extension. From these findings, the nurse can infer that the fetus is presenting in left occiput anterior position and the head is born in extension. A head born in flexion does not require restitution. In the left occiput posterior position, the fetal head will be facing the right thigh. pp. 124-125, 128
On electronic fetal monitoring, the nurse finds that the fetal heart rate decelerates by 15 beats per minute below baseline. This effect lasts for 1 minute. The nurse also finds altering V-shaped and W-shaped curves on the monitor. What does this finding indicate? Fetal respiratory acidosis
Variable decelerations is a condition in which the fetal heart rate decreases by up to 15 beats/min below baseline, lasting from 15 seconds to 2 minutes, and ends with U-, V- or W-shaped curves on the monitor. It occurs as a result of compression of the umbilical cord around the fetal neck and results in fetal respiratory acidosis.
On electronic fetal monitoring, the nurse finds that the fetal heart rate decelerates by 15 beats per minute below baseline. This effect lasts for 1 minute. The nurse also finds altering V-shaped and W-shaped curves on the monitor. What does this finding indicate?
Variable decelerations is a condition in which the fetal heart rate decreases by up to 15 beats/min below baseline, lasting from 15 seconds to 2 minutes, and ends with U-, V- or W-shaped curves on the monitor. It occurs as a result of compression of the umbilical cord around the fetal neck and results in fetal respiratory acidosis. p. 135
The nurse is assisting the primary health care provider during an amniotomy in a patient. The nurse finds that the amniotic fluid of the patient has white flecks. What would be the probable reason for this finding in the patient?
Vernix in the amniotic fluid Clear amniotic fluid with white flecks is a normal finding. The white flecks in the amniotic fluid are present due to the occurrence of vernix, a skin protectant on the fetus. Amniotic fluid with a sweet smell is normal and does not indicate infection. Clear amniotic fluid with flecks of white vernix is also a normal finding.
Which presentation involves a full flexion of the head and the fetus is in the left occiput anterior position?
Vertex presentation. 123
Which cultural practice does the nurse observe in a Vietnamese patient during labor? Suffers in silence
Vietnamese patients are expected to keep silent during labor as a part of their cultural practices. patients keep their body covered during labor. Vietnamese patients generally prefer the upright position for labor and delivery. They prefer to drink warm fluids postpartum. p119
The primary health care provider prescribes vitamin K (AquaMEPHYTON) to an infant 1 hour after birth. What is the reason behind this?
Vitamin K assists in blood clotting and is produced by the intestinal flora of the body. These intestinal flora are absent in infants. Hence, vitamin K (AquaMEPHYTON) must be provided 1 hour after birth.
The nurse is assisting a patient in labor. The nurse finds that the fetus is presented in a footling breech position Which finding enabled the nurse to make such a conclusion?
When both feet of the fetus are at the cervix, the fetus
The nurse is assisting a patient in labor. The nurse finds that the fetus is presented in a footling breech position. Which finding enabled the nurse to make such a conclusion? Presence of both feet of the fetus at the cervix
When both feet of the fetus are at the cervix, the fetus is in a footling breech position. If the fetus is in the left occiput anterior position, the fetus is in a vertex presentation. The right mentum anterior position is a face presentation, but not a fetal body presentation.
The nurse is assisting the primary health care provider during an amniotomy in a patient. The nurse finds that the amniotic fluid of the patient has Yellow-colored and an offensive odor. What would be the probable reason for this finding in the patient? The nurse is inspecting the amniotic fluid of a patient following the rupture of the amniotic sac during labor. The nurse finds that the patient's body temperature is elevated and suspects that the patient has an infection. Which finding enabled the nurse to make this
Yellow-colored amniotic fluid and an offensive odor indicate infection in the patient. An elevated temperature indicates infection in the pregnant woman. When there is an increase in the body temperature, the amniotic fluid of the patient should also be evaluated for signs of infection p. 137
When 3 to 4 cm of the fetal head is visible at the vaginal opening, this is known as:
crowning. p. 143-145
Which finding in the patient indicates a vaginal bleeding?
dark red in color during postpartum and is called lochia rubra. Pale brown vaginal bleeding does not indicate vaginal lacerations; it occurs when lochia rubra subsides. p. 147
which presentation involves a full extention of the head and the fetus Presence of the fetus in the right mentum anterior position
face presentation
Which presentation involves the full extension of the fetal head and the face of the uterus and enters the pelvis first? it is in The right mentum anterior position
face presentation.
What is the disadvantage of delivering at home? Delay in reaching emergency service
if the mother or child encounters a life-threatening situation, there may be a significant delay in reaching emergency care. limited choice of birth attendants only lay midwives are available. possibility of no preestablished relationship with a physician in case an emergency arises that necessitates the woman or newborn to be transferred to a hospital.
Based on their strength, uterine contractions are classified into three phases:
increment, peak, and decrement
in Which presentation the fetal head is neither flexed nor extended ?
military presentation. p. 123
The nurse is caring for a Central American patient during the immediate postpartum period. Which cultural practice does the nurse observe in the patient?
patient wear red clothing during labor. p. 117
Which cultural practice does the nurse observe in a Puerto Rican patient during labor?
patients keep their body covered during labor.
The nurse is caring for an arabic newborn. Which cultural practice does the nurse observe?
the father whispers praises in the newborn's ear.
The nurse is assisting a patient in labor. The nurse finds that the fetus is presented in a vertex presentation.. Which finding enabled the nurse to make such a conclusion?
the fetus is in the left occiput anterior position,
"Presentation" is a term that indicates the fetal part that enters the pelvis first. There are four types of cephalic presentation:
vertex presentation, military presentation, brow presentation, and face presentation. p. 123
