Chapter 14: Nursing Management During Labor and Birth
A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?
"I respect your preference, whether it is to have medication or not."
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 If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.
The is used during external electronic monitoring to detect changes in uterine pressure.
tocotransducer
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?
respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.
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."
fetal heart rate refers to the average fetal heart rate that occurs during a 10-minute period.
Baseline
Continuous external fetal monitoring involves the use of a spiral electrode.
FALSE
The length of the cervix assessed during a vaginal examination determines cervical dilation.
False
The fetal heart rate is heard most clearly at the fetal
back
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
The student nurse is preparing to assess the fetal heart rate (FHR) and 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. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
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. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.
When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?
: Fetal heart rate acceleration occurs.
A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?
Determine if the client is in true or false labor.
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.
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?
Support the client's decision and call the provider.
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?
Clear to straw-colored fluid The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present. m .k
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
Assess vital signs.
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 assesses fetal heart rate at least every 15 to 30 minutes during the active phase of labor.
TRUE
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 is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?
Continue to massage the client's fundus The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.
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.
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?
Inspect the perineum.
A fetal heart rate of 140 beats per minute would be considered within the normal range.
TRUE
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this 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.
As a woman enters the second stage of labor, which would the nurse expect to assess?
feelings of being frightened by the change in contractions
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?
headache following anesthesia
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?
ischial spine
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations -4 station -2 station 0 station +2 station +4 station
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.
Normal oxygen saturation of a healthy fetus is 30% to
70%
Meperidine would be used to reverse the effects of central nervous system depression from opioid administration during labor.
FALSE
A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?
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?
FHR fluctuates over 25 beats per minute.
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 caring for a client who prefers resting on her back during the labor process. To facilitate client wishes, which nursing action is required?
Utilize a wedge under one hip Changing positions frequently can help during the labor process. By placing a wedge under the client's hip, it decreases the likelihood of hypotension and allows the nurse to protect the fetus from decreased oxygenation and meet client wishes. This option is the only one in which the staff is meeting client wishes. The head of the bed may be elevated as needed. Depending upon the location of the fetus, the tocometer is placed where fetal heart tones are able to be heard. Rarely is the knee gatch elevated as it may slow blood flow.
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?
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
A refers to a transient fall in fetal heart rate due to stimulation of the parasympathetic nervous system.
deceleration
The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply.
pruritis hypotension respiratory depression
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia."
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver.