Chapter 14: Nursing Management During Labor and Birth
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:
7.15 or less.
A pregnant patient received a narcotic analgesic 2 hours before delivery. The newborn is lethargic and difficult to arouse. What should the nurse prepare to do to help this newborn?
Administer naloxone hydrochloride.
A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method?
Counterirritation stimulation blocks pain from traveling to the spinal cord.
The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?
Initiate comfort measures
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?
starting an IV and hanging IV fluids
To assess the frequency of a woman's labor contractions, the nurse would time:
the beginning of one contraction to the beginning of the next.
A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response?
A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.
The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?
"The analgesia will reduce the sensation of pain for a limited period of time."
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?
Tachycardia and a falling blood pressure
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?
A positive Nitrazine test
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?
Client priorities and preferences are incorporated into the plan.
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?
Difficulty breathing
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
Inability to push
There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?
It can be administered by the nurse.
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status
At what time is the laboring client encouraged to push?
When the cervix is fully dilated
The nurse is providing preoperative care for a client who will undergo a cesarean section. The nurse should:
confirm that consent has been provided by the client.
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
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?
naloxone
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?
Thoroughly wash the hands before and after client contact.
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?
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
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.
Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.
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?
110 to 160 bpm
How does a woman who feels in control of the situation during labor influence her pain?
Feelings of control are inversely related to the client's report of pain.
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?
"The baby is coming. I'll explain what's happening and guide you."
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?
Continuous labor support
The laboring client who is at 3 cm dilation 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?
This may prolong labor and increase complications.
An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification?
"The client reports a pain level of 8. She has a low pain tolerance."
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
"The injection is given in the space outside the spinal cord."
The spouse of a pregnant patient is concerned about the risk of paralysis from an epidural block being used during labor. How should the nurse respond to the spouse's concern?
"The injection is given in the space outside the spinal cord."
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
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?
10:30 a.m.
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR.
The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?
Acute pain related to uterine contractions
Which statement is true regarding analgesia versus anesthesia?
Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.
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?
Anxiety can slow down labor and decrease oxygen to the fetus.
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?
Assess fetal heart rate.
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
Assess for labor progression.
A nurse notes the digital readings of the electronic fetal monitor shows decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus?
Central nervous system
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions.
Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms?
Electrical impulses are created that interfere with nerve transmission.
The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?
Fear of pain during labor
A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?
Inhale slowly through nose and exhale through pursed lips.
The pain of labor is influenced by many factors. What is one of these factors?
The woman is prepared for labor and birth.
The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?
On the uterine fundus
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?
Palpate the mother's radial pulse at the same time.
The nurse is preparing to administer an intradermal water injection to a client who is in labor. Which action should the nurse prioritize?
Prepare four 1 mL syringes of 0.05 to 0.1 mL sterile water using a 25 gauge needle.
The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?
This is a technique to prevent the painful stimuli from entering the brain.
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
During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective?
The patient is not requesting pain medication.
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?
acme
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?
administration of oxygen by mask
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:
left lower quadrant.