Chapter 14 Prep-U OB (easy)
Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be most likely? A. 144 beats per minute B. 164 beats per minute C. 154 beats per minute D. 134 beats per minute
C R: A fetal heart rate of 164 beats per minute (bpm) indicates fetal tachycardia. The normal range of FHR is between 120 and 160 bpm. When the FHR is above 160 bpm, it should be considered as fetal tachycardia. Therefore, a FHR of 164 beats per minute is considered tachycardia.
To assess the frequency of a woman's labor contractions, the nurse would time: A. the interval between the acme of two consecutive contractions. B. the end of one contraction to the beginning of the next. C. how many contractions occur in 5 minutes. D. the beginning of one contraction to the beginning of the next.
D
When developing a labor plan with the client, which outcome is the priority? A. The client will direct her pain management techniques. B. The client will deliver the fetus vaginally. C. The client will attend all prenatal classes prior to delivery. D. The client will be pain-free during the labor process.
A R: Clients who have their pain managed report higher satisfaction with the birth experience. By working with the nurse in determining the labor plan, the health care provider, nurse and the client can work together to obtain a plan to manage labor pain. This puts the client in control of her care. The client nor the nurse is able to determine if a vaginal birth is feasible. It is rarely realistic to have a pain-free labor. Some discomfort is felt sometime within the labor process. It is strongly encouraged to have attended prenatal classes but not the priority.
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? A. less anxiety B. decreased sedation C. increased cervical dilation D. increased feelings of control
A R: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? A. A urine dipstick test to check for protein B. An ultrasound to determine fetal age C. A blood culture to note any infection of the blood D. A urine culture to rule out a urinary tract infection
A R:Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.
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? A. ischial spine B. pubic symphysis C. cervical os D. ischial tuberosity
A R:Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as zero station.
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? A. Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels B. distraction of the brain cortex by other stimuli C. release of endorphins in response to contractions D. blocking of nerve transmission via mechanical irritation of nerve fibers
A R: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process? A. Just before birth B. Just after birth C. Before dilation only D. Early stage labor
A R: Pudendal block is a local block in the perineal area and is used to numb for birth. Application before labor begins or while labor is in its early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over.
How does a woman who feels in control of the situation during labor influence her pain? A. Feelings of control are inversely related to the client's report of pain. B. Decreased feeling of control helps during the third stage. C. There is no association between the two factors. D. Feeling in control shortens the overall length of labor.
A R: Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.
The nurse is providing preoperative care for a client who will undergo a cesarean section. The nurse should: A. confirm that consent has been provided by the client. B. educate the client about the potential benefits of vaginal birth. C. explain the risks and benefits of cesarean section. D. confirm that the client has not had a previous vaginal birth.
A R: The nurse does not obtain the client's consent, but should confirm that it has been obtained. Explaining the relative risks and benefits of each type of birth is beyond the nurse's scope. Previous vaginal birth does not rule out a cesarean section.
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? A. Help the client regain control of her breathing technique. B. Notify the RN that client's blood pressure has increased. C. Notify the RN about the lack of FHR variability. D. Assist the client into a hands-and-knees position.
A R: The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is not improvement, notify the RN. Putting the patient in the hands-and-knees position should be avoided until later in labor.
A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? A. Ambulation ad lib B. Complete bed rest C. Bathroom privileges D. Up in chair TID
A R: To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.
Which assessment finding is most important as labor progresses? A. The uterus relaxes completely between contractions. B. The client is remaining in control of emotions. C. Labor is completed within 18 hours. D. The pulse and respirations rise with the work of labor.
A R:It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.
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? A. Thoroughly wash the hands before and after client contact. B. Replace soiled drapes and linen as needed. C. Clean the woman's perineum with a Betadine scrub. D. Strictly follow universal precautions.
A R:The most important infection control technique in any health care setting is thoroughly washing hands on a routine basis. Keeping the area clean is secondary, but is also important.
The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? A. do nothing, this is benign B. reposition the client on either side C. notify the health care provider D. palpate for bladder fullness
B R: Deceleration may be related to compression on the maternal abdominal aorta and inferior vena cava and repositioning the woman to either her right or left side will remove the pressure and allow the blood flow to resume. If this is not effective then the nurse would look for other potential causes such as an infusion of oxytocics. If this is unsuccessful the RN and health care provider needs to be notified immediately. The fetus is not getting enough oxygen and needs intervention. Palpating for bladder fullness would not be appropriate at this time. This is a serious situation developing and needs prompt intervention.
Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor? A. Development of respiratory depression in the newborn Interference with the ability to concentrate on contractions B. Interference with blood coagulation with increased risk of bleeding in mother or infant C. Competition with bilirubin-binding sites in fetal D. Circulation increases risk of kernicterus
B R: Acetylsalicylic acid (aspirin) is documented to cause interference with blood coagulation.
The nurse is providing a report on a gravida 3 para 2 client. The nurse states that the client is fully effaced, 7 cm dilated, station +1, and contractions every 8 minutes. Which nursing action is most important at this time? A. Discuss contraction intensity. B. Record tocodynamometer readings. C. Obtain vital signs. D. Ambulate the client in the hall.
B R: From the report, it is understood that the client's labor is progressing. The most important nursing action at this time is to assess how the fetus is tolerating the labor process via the tocodynamometer. The nurse would also obtain vital signs and discuss pain management and contraction intensity. Depending upon the progression of the labor and how the client is feeling, the client may not ambulate in the hall.
The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper? A. Pink B. Blue C. Yellow D. White
B R: If the fluid in the vaginal canal is amniotic fluid, the Nitrazine paper will turn a dark blue, the color of an alkaline fluid, and this is a positive Nitrazine test for rupture of membranes.
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? A. A machine is used to measure the patient's ability to relax during contractions. B. Counterirritation stimulation blocks pain from traveling to the spinal cord. C. Small injections of sterile saline reduce are used to reduce the amount of back pain. D. Needles are inserted along meridians to release endorphins and control pain.
B R: Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors. Low-intensity electrical stimulation blocks the afferent fibers, preventing pain from traveling to the spinal cord synapses from the uterus. Needles being inserted along meridians to release endorphins explain acupuncture. A machine to measure the patient's ability to relax during contractions explains biofeedback. Small injections of saline to reduce back pain explain intracutaneous nerve stimulation.
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? A. fetal scalp stimulation B. administration of oxygen by mask C. tactile stimulation D. application of vibroacoustic stimulation
B R: 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.
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? A. 100 to 150 bpm B. 110 to 160 bpm C. 90 to 140 bpm D. 120 to 170 bpm
B R:The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? A. Alert the team that internal fetal monitoring may be needed. B. Encourage the client to push. C. Palpate the area just above the symphysis pubis. D. Institute effleurage and apply pressure to the client's lower back during contractions.
C R:Palpate to determine if the infant is engaged and what the presenting part of the infant is by the symphysis pubis; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign? A. "This means +1 and the baby is entering the true pelvis." B. "This indicates that you start labor within the next 24 hours." C. "The presenting part is at the true pelvis and is engaged." D. "This is just a way of determining your progress in labor."
C R:Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.
Which order by the health care provider would the nurse question if given in the active stage of labor? A. Positioning with pillows B. Out of bed with assistance C. Secobarbital for relaxation D. Ice chips as requested.
C R: A sedative, such as secobarital, is given in early labor to promote sleep or a hypertonic contraction pattern. This class of barbiturates can cause respiratory and central nervous system depression if given within 12 to 24 hours of birth. Ice chips may be provided to decrease symptoms of dry mouth. Providing client positioning with the use of pillows for support may allow the client to relax between contractions. For safety reasons, primarily during an intense contraction, the client needs assistance while out of bed.
When developing a labor plan with the client, which outcome is the priority? A. The client will deliver the fetus vaginally. B. The client will attend all prenatal classes prior to delivery. C. The client will direct her pain management techniques. D. The client will be pain-free during the labor process.
C R: Clients who have their pain managed report higher satisfaction with the birth experience. By working with the nurse in determining the labor plan, the health care provider, nurse and the client can work together to obtain a plan to manage labor pain. This puts the client in control of her care. The client nor the nurse is able to determine if a vaginal birth is feasible. It is rarely realistic to have a pain-free labor. Some discomfort is felt sometime within the labor process. It is strongly encouraged to have attended prenatal classes but not the priority.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A. Use the Valsalva maneuver for effective pushing. B. Stay low on her back to ease the back pain. C. Use a birthing ball and find a position of comfort. D. Ask for privacy, and have just the partner present.
C R:The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.
On examination, the nurse determines the client is at 50% effacement. This means: A. the cervical canal is 1.5 cm long. B. the cervical canal is 2 cm long. C. the cervical canal is 1 cm long. D. the cervical canal is 2.5 cm long.
C R: Effacement refers to the length of the cervical canal. At 0%, the cervical canal is 2 cm long; at 50%, 1 cm long; and at 100%, the cervical canal is obliterated.
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding? A. 75% effaced. B. 0% effaced. C. 100% effaced. D. 50% effaced.
D R: A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 0.5 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.
Which intervention would be least effective in caring for a woman who is in the transition phase of labor? A. urging her to focus on one contraction at a time B. providing one-to-one support C. having the client breathe with contractions D. encouraging the woman to ambulate
D R: Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.
The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which techniuqe during labor? A. Water therapy B. Hypnosis C. Patterned birthing D. Attention focusing
D R: Attention focusing is the use of an object or picture or image for the woman to reflect and focus on (internally or externally) during labor to distract her from the labor pain. Hypnosis is a psychological state. Water therapy involves the woman sitting in water to relax. Patterned breathing involves the woman controlling her breathing patterns during contractions and "breathing through" them to help control the pain. The attention focusing, patterned breathing, water therapy, and hypnosis are all variations of relaxation which may be used by the client during the birthing process.
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? A. "The injection is given in the space outside the spinal cord." B. "I have never read or heard of this happening." C. "An injury is unlikely because of expert professional care given." D. "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."
A R: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.
A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process? A. Patient uses breathing techniques to control anxiety and pain during labor. B. Patient tolerates the use of sanitary napkins to absorb vaginal secretions during labor. C. Patient requests pain medication throughout the labor process. D. Patient refuses complementary and alternative techniques to control pain during labor.
A. R: An outcome that indicates that the patient has less anxiety during labor and delivery would be the use of breathing techniques to control anxiety and pain during labor. Requesting pain medication, using sanitary napkins, and refusing complementary and alternative pain management techniques are not appropriate outcomes for labor and delivery.
A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated? A. "I would like the baby's father to cut the umbilical cord." B. "I will remain in my bed for my labor and birth like last time." C. "We will hire a doula for our labor support." D. "My 6-year old son will be in the birthing room, too."
B R: The nurse should educate the client that she will be encouraged to get out of bed during labor. In the labor and birth process, many positions, ambulation, and water therapy may be used for comfort and positioning. All other answers are appropriate client responses.
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? A. "It disrupts the nerve signal of pain via mechanical irritation of the nerves." B. "It distracts your brain from the sensations of pain." C. "It causes the release of endorphins." D. "It blocks the transmission of nerve messages of pain at the receptors."
B R: Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? A. every 20 minutes B. every 10 minutes C. every 5 minutes D. every 15 minutes
D R: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.
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:
In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.
Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication?
"I have no pain now." R: The advantage of intrathecal medication administration is that the medication is effective almost immediately. The medication is placed in the subarachnoid space. The other options still have the client feeling some discomfort.
A multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is best? A. Have the client ambulate in the hall and recheck. B. Have the client rest in bed on her left side. C. Send the client home and return if contractions increase D. Admit the client directly to the labor and delivery area
A R:To determine if the client is in true labor, the nurse is most correct to have her walk in the hall for approximately an hour. At that point, the client is rechecked to identify if labor has progressed. If labor has progressed, the client is admitted. Having the client rest in bed is not helpful to assist in labor progression.
A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate adminstering? A. tenofovir B. zidovudine C. maraviroc D. nevirapine
B Zidovudine (ZDV) is recommended to reduce perinatal transmission of HIV (2mg/kg IV over an hour, and then a maintenance infusion of 1 mg/kg per hour until birth) or a single 200-mg oral dose of nevirapine at the onset of labor. Since this client presented in the late stages, zidovudine would be the better choice. Tenofovir and maraviroc are also HIV medications, but they are not the better choices for this scenario.
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? A. Massaging the client's lower back B. Placing a wedge under the hips C. Providing a paper bag D. Rubbing the client's legs
B R: Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension. Rubbing the legs or massaging the back can relax the client between intense contractions but those actions do not prevent a complication. Providing a paper bag prevents hyperventilation typically caused by pattern breathing.
In providing culturally competent care to a laboring woman, which is a priority? A. Identify any cultural foods used prior to labor. B. Identify who is the support person during the labor. C. Identify how the client expresses labor pain. D. Identify the decision maker within the family.
C R: Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
Every 15 minutes R: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.
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!"? A. Inspect the perineum. B. Auscultate the fetal heart tones. C. Contact the primary care provider. D. Time the contractions.
A R:The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, the heart sounds, contraction rate, and contacting the primary care provider can all be done, if there is time.
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? A. This is a technique to prevent the painful stimuli from entering the brain. B. Pain perception is decreased if anxiety is present. C. The gate control mechanism is located at the pain site. D. The gate control mechanism opens so all the stimuli pass through to the brain.
A R:Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location.
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. Notify the healthcare provider. C. Ask if this is the client's first pregnancy. D. Assess to see if the client has any drug allergies.
A R: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 healthcare provider should be notified once the nurse knows the client's current status.
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction? A. acme B. diastole C. decrement D. increment
A R: The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction.
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? A. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. B. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. C. Women report higher levels of satisfaction when regional anesthetics are used to control pain. D. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.
B
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? A. Emotions are calm and happy. B. The urge to push occurs. C. Frequency of contractions are 5 to 6 minutes. D. Fetus is at -1 station.
B R: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.
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 hydration status. B. Assess amount of cervical dilation. C. Monitor vital signs. D. Obtain urine specimen for urinalysis.
B R: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.
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? A. A quick epidural can replace the need for pain medication. B. Continuous support through the labor process helps decrease the need for pain medication. C. Sitting in a hot tub helps decrease the need for pain medication. D. Lying on an ice pack can help decrease the need for pain medication.
B R: 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.
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? A. "Do you want me to call in your family?" B. "The baby is coming. I'll explain what's happening and guide you." C. "The baby is coming. Relax and everything will turn out fine." D. "Even though the baby is coming, the health care provider will be here soon."
B R: Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication? A. epinephrine B. naloxone C. indomethacin D. ampicillin
B R: Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor.
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? A. The client is more sensitive to preanesthetic medications. B. The client is less sensitive to inhalation anesthetics. C. Neonatal depression is possible. D. Fetal hypersensitivity to anesthetic is possible.
C R: General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.
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? A. Greenish fluid B. Bloody fluid C. Clear to straw-colored fluid D. Cloudy white fluid
C R: 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.
A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response? A. "Your health care provider knows what is best for you." B. "The pain relief offered will compensate for the discomfort afterward." C. "Spinal headache is not a usual complication of epidural blocks." D. "The anesthesiologist will do her best to avoid this."
C R: Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."
The nurse is caring for a client who is diagnosed with a spinal headache. When completing a nursing assessment, which position would exacerbate the symptoms? A. Recumbent lateral position B. Supine C. Fowler's position D. On the left side
C R:A spinal headache occurs when the client is in an upright position and is relieved when the client is laying down and still. The nurse is correct to avoid placing the client in the Fowler's or upright position. The other positions may be attempted to assess client symptoms.
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? A. Notify the RN about the lack of FHR variability. B. Notify the RN that client's blood pressure has increased. C. Help the client regain control of her breathing technique. D. Assist the client into a hands-and-knees position.
C R:The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is not improvement, notify the RN. Putting the patient in the hands-and-knees position should be avoided until later in labor.
The pain of labor is influenced by many factors. What is one of these factors? A. The woman has lots of visitors during labor. B. The woman has a high threshold for pain. C. The woman is prepared for labor and birth. D. The woman has a high tolerance for pain.
C R: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.
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? A. Pain pathway blockage B. Massage C. Abdominal imagery D. Effleurage
D R: 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 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? A. Administering an opioid such as meperidine or fentanyl B. Immersing the client in warm water in a pool or hot tub C. Administering a sedative such as secobarbital or pentobarbital D. Practicing effleurage on the abdomen
D R: In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A. Help the woman to sit up in a semi-Fowler's position. B. Ask her to pant with the next contraction. C. Administer oxygen at 3 to 4 L by nasal cannula. D. Turn her or ask her to turn to her side.
D R: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? A. Fetal baseline rate increasing at least 5 mm Hg with contractions B. Variable decelerations, too unpredictable to count C. a shallow deceleration occurring with the beginning of contractions D. fetal heart rate declining late with contractions and remaining depressed
D R: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.
Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first? A. Place the patient supine. B. Ask the patient to take deep breaths. C. Raise the head of the bed. D. Turn onto the left side or raise the legs.
D R: To help prevent supine hypotension syndrome, place the pregnant patient on the left side after an epidural block. If hypotension should occur, the patient's legs should be raised in addition to providing oxygen, intravenous fluids, and medication. The supine position encourages hypotension syndrome. Raising the head of the bed and deep breathing are not interventions to help with hypotension syndrome.
In the labor and delivery unit, which is the best way to prevent the spread of infection? A. Use sterile gloving B. Provide clean gloves in the room C. Limit vaginal examinations D. Complete hand hygiene
D R: Hand hygiene remains the number one way to prevent the spread of infection. It is appropriate to use sterile gloving for invasive procedures and limit vaginal examinations as much as possible. Providing clean gloving is also important when there is exposure to blood and body secretions.
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? A. Anxiety will increase blood pressure, increasing risk with an epidural. B. Increased anxiety will increase the risk for needing anesthesia. C. Decreased anxiety will increase trust in the nurse. D. Anxiety can slow down labor and decrease oxygen to the fetus.
D R: 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.
