Chapter 14: Nursing Management During Labor and Birth

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the FHR with the Doppler at least how often? a) every 15 to 30 minutes b) every 30 minutes c) every hour d) continuously

C Rationale: During the latent phase of labor, the nurse should monitor the FHR every 30-60 minutes. FHR should be monitored every 30 minutes in the active phase and every 15-30 minutes in the transition phase of labor. Continuous monitoring is done when an electronic fetal monitor is used.

A pregnant client with a history of spinal injury is being prepared for a Cesarean birth. Which method of anesthesia is to be administered to the client? a) local infiltration b) epidural block c) regional anesthesia d) general anesthesia

D Rationale: General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nurses to number the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

Third degree laceration

extends through the anal sphincter muscle

If the nitrazine test is inconclusive, an additional test, called the ________ test, can be used to confirm rupture of membranes

fern

Fetal ______________ are transitory increases in the FHR above the baseline that are associated with sympathetic nervous stimulation.

accelerations

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? a) monitor vital signs b) assess amount of cervical dilation c) obtain urine specimen for urinalysis d) monitor hydration status

B Rationale: If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.

A nurse is required to obtain the fetal heart rate for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly? a) lower quadrant of the maternal abdomen b) at the level of the maternal umbilicus c) above the level of the maternal umbilicus d) just below the maternal umbilicus

A Rationale: In 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 nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? a) respiratory rate b) temperature c) Pulse d) uterine contractions

A Rationale: The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression.

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? SATA a) determining the presentation of the fetus b) determining the position of the fetus c) determining the lie of the fetus d) determining the weight of the fetus e) determining the size of the fetus

A, B, C Rationale: Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

________________________ describes the irregular variations or absence of fetal heart rate (FHR) due to erroneous causes on the fetal monitor record.

Artifact

The nurse caring for a client in preterm labor observes abnormal FHR patterns. Which nursing intervention should the nurse perform next? a) application of vibroacoustic stimulation b) tactile stimulation c) administration of oxygen by mask d) fetal scalp stimulation

C Rationale: 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.

A 29 week gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? a) Prepare the client for birth b) Assess the client's cervical status c) notify the health care provider d) perform Leopold's maneuver

C Rationale: The nitrazine tape shows a pH between 5-6 which indicates an acidic environment with the presence of vaginal fluid and less blood. If the membranes had ruptured, amniotic fluid was present, or there was excess blood, the nitrazine test tape would have indicated an alkaline environment. The nurse would notify the HCP for further assessment of the client.

What are the advantages and disadvantages of continuous electronic fetal monitoring?

Pros: produces a continuous record of the FHR Cons: limits maternal movement and encourages her to lie in supine position, reducing placental perfusion

What is the purpose of vaginal examination during maternal assessment?

To assess the amount of cervical dilation, the percentage of effacement, and the fetal membrane status. Helps gather information about presentation, position, and station.

What does the Apgar score assess?

hear rate, respiratory effort, muscle tone, response to irritation stimulus, and color

If the woman is diabetic, it is critical to alert the newborn nursery of potential ____________ in the newborn

hypoglycemia

What are the typical signs of the second stage of labor?

increase in apprehension or irritability spontaneous ROM sudden appearance of sweat on upper lip increase in bloody show low grunting sounds complaints of rectal and perineal pressure beginning of involuntary bearing down efforts

What positions are used for the second stage of labor?

lithotomy (feet in stirrups) semi-sitting lateral/side-lying birthing stool squatting kneeling/ hands and knees

What information should a nurse include when taking the maternal health history?

name and age care provider prenatal record data past health and family history prenatal education medications risk factors reason for admission history of previous preterm births allergies the last time the client ate method for feeding name of attendant and pediatrician pain plan

____________ comfort measures are usually simple, safe, effective, and inexpensive to use

non-pharmacologic

Fourth degree laceration

through anterior rectal wall

Second Degree laceration

through the muscles of the perineal body

First degree laceration

through the skin

The ____________________ is placed over the uterine fundus in the area of greatest contractility to electronically monitor uterine contractions.

tocotransducer

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? a) external electronic fetal monitoring b) fetal blood pH c) fetal oxygen saturation d) fetal position

A Rationale: Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through the ultrasonography or abdominal palpation but is not indicative of fetal oxygenation.

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? a) increased sedation b) newborn respiratory depression c) nervous system depression d) decreased alertness

A Rationale: Increased sedation is an adverse effect of lorazepam. Diazepam and midazolam cause CNS depression for both the woman and the newborn. Opioids are associated with newborn respiratory depression and decreased alertness.

A nurse caring for a pregnant client in labor observes that the FHR is below 110 beats per minute. Which interventions should the nurse perform? SATA a) turn the client on her left side b) reduce IV fluid rate c) administer oxygen by mask d) assess client for underlying causes e) ignore questions from the client

A, C, D Rationale: The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? a) Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds b) Inhale slowly though nose and exhale through pursed lips c) Punctuated breathing by a forceful exhalation through pursed lips every few breaths d) hold breath for 5 seconds after every 3 breaths

B Rationale: For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-paced breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every 3 breaths is not recommended in any of the three levels of patterned breathing.

Baseline variability represents the interplay between the ______________ and sympathetic nervous systems

parasympathetic

The primary power of labor is/are _______________ contractions, which are involuntary.

uterine

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated FHR changes. What intervention should the nurse perform to manage the changes? a) assist client to a supine position b) provide supplemental oxygen c) discontinue IV fluid d) turn client to her right side

B Rationale: The nurse should provide supplemental oxygen if a client who has been administered combined spinal-epidural analgesia exhibits signs of hypotension and associated FHR changes. The client should be assisted to a semi-fowler position; the client should not be kept in a supine position or be turned on her left side. Discontinuing IV fluid will cause dehydration.

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs? a) every 15 minutes b) every 30 minutes c) every 45 minutes d) every 1 hour

B Rationale: When a pregnant client is in the active phase of labor, the nurse should monitor the vital signs every 30 minutes. The nurse should monitor the vital signs every 30-60 minutes if the client is in the latent phase of labor and every 15-30 minutes during the transition phase of labor. Temperature is usually monitored every 4 hours in the active phase of labor.

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the clients uterus is relaxed upon massage. What would the nurse do next? a) continue to monitor the client b) continue to massage the client's fundus c) administer oxygen to the client d) assess the client's vaginal bleeding

B Rationale: 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.

The __________________ spines serve as landmarks for estimating the descent of the fetal presenting part and have been designated as zero station.

ischial

The nurse reviews the prenatal record to identify risk factors that may contribute to a decrease in _____________ circulation during pregnancy and/or labor.

uteroplacental

A pregnant client requires administration of an epidural block for management of pain during labor For which conditions should the nurse check the client before administering the epidural block? SATA a) spinal abnormality b) hypovolemnia c) varicose veins d) coagulation defects e) skin rashes or bruises

A, B, D Rationale: The nurse should check for any abnormality of the spine, hypovolemia, or coagulation defects in the client. An epidural is contraindicated in women with these conditions. Varicose veins and skin rashes or bruises are not contraindications for epidural block but are for massage.

A pregnant client has opted for hydrotherapy for pain management during labor Which should the nurse consider when assisting the client during the birthing process? a) Initiate the technique only when the client is in active labor b) Do not allow the client to stay in the bath for long c) Ensure that the water temperature exceeds body temperature d) Allow the client into the water only if her membranes have ruptured

A Rationale: The recommendation for initiating hydrotherapy is that women be in active labor to prevent the slowing of labor contractions secondary to muscular relaxation. Woman are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temp should not exceed body temp. The woman's membranes can be intact or ruptured.

A 39 week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? a) determine if the client is in true or false labor b) Ask if this is the client's first pregnancy c) notify the health care provider d) assess to see if the client has any drug allergies

A rationale: When a nurse first comes in contact with a pregnant client, it is important to first ascertain whether the woman is in true or false labor. Information regarding the number of pregnancies or history of drug allergy is not important criteria for admitting the client. The health care provider should be notified once the nurse know the client's current status.

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

A, B, E Rationale: The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and BP is part of the general physical exam and does not help to monitor uterine contraction.

A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client? SATA a) estimated due date b) history of drug abuse c) characteristics of contractions d) appearance of vaginal blood e) history of drug allergy

A, C, D Rationale: When conducting an admission assessment on the phone for a pregnant client, the nurse needs to obtain information regarding the estimated due date, characteristics of contractions, and appearance of vaginal blood to evaluate the need to admit her. History of drug abuse or a drug allergy is usually recorded as part of the client's medical history.

Given below, in random order, are nursing interventions during various stages of labor and birth. Arrange them in the correct order. a) Check the fundus to ensure that it is firm (size and consistency of a grapefruit), located in the mid-line and below the umbilicus b) ascertain whether the woman is in true or false labor c) position the woman and cleanse the vulva and perineal areas d) check for lengthening of the umbilical cord protruding from the vagina e) check for crowning, low grunting sounds from the woman, and increase in blood-tinged show.

B, A, C, E, D