Chapter 14 PrepU
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? 10:05 a.m. 10:30 a.m. 11:15 a.m. 11:30 a.m.
Correct response: 10:30 a.m. Explanation: Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives narcotics or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia maternal hypertension and fetal tachycardia
Correct response: maternal hypotension and fetal bradycardia Explanation: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.
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. Reduce intravenous (IV) fluid rate. Administer oxygen by mask. Assess client for underlying causes. Ignore questions from the client.
Correct response: Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. Explanation: 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 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? "An injury is unlikely because of expert professional care given." "I have never read or heard of this happening." "The injection is given in the space outside the spinal cord." "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."
Correct response: "The injection is given in the space outside the spinal cord." Explanation: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.
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? Monitor vital signs. Assess amount of cervical dilation. Obtain urine specimen for urinalysis. Monitor hydration status.
Correct response: Assess amount of cervical dilation. Explanation: 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.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Test a sample of amniotic fluid for protein. Ask her to bear down with the next contraction. Elevate her hips to prevent cord prolapse. Assess fetal heart rate for fetal safety.
Correct response: Assess fetal heart rate for fetal safety. Explanation: Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.
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 maternal blood pressure. Assess for constipation. Assess for dry mouth. Assess fetal heart rate.
Correct response: Assess fetal heart rate. Explanation: After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize? Assess return of sensory and motor functions to the lower extremities. Help the client get up and walk around immediately. Let the client rest and recover while keeping her legs slightly elevated. Make sure the client receives plenty of fluids.
Correct response: Assess return of sensory and motor functions to the lower extremities. Explanation: After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time (at least until the medication wears off). Do not elevate the legs; the goal is to maintain normal circulation. Fluids are important, but they are not related to the epidural or to the metabolism of the medication.
A client has just received combined spinal epidural. Which nursing assessment should be performed first? Assess vital signs. Assess pain level using a pain scale. Assess for progress in labor. Assess for spontaneous rupture of membranes. Assess for fetal tachycardia.
Correct response: Assess vital signs. Explanation: The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.
A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform? Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Assist the client to a sitting position, assess the fetal heart rate, give naloxone, and administer oxygen via face mask. Assist the client to the supine position, recheck the blood pressure, and administer an IV bolus of 1000 ml. Assist the client to Trendelenburg position, assess the fetal heart rate, and administer oxygen via face mask.
Correct response: Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Explanation: In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler position owing to the risk of supine hypotension in the supine position and in Trendelenburg position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? Have the client lightly push to meet the need. Have the client pant and blow through the contraction. Have the client divert the energy to squeezing a hand. Assist the client to a Fowler position.
Correct response: Have the client pant and blow through the contraction. Explanation: The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.
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. Ask the woman to hold her breath while assessing the FHR. Have the woman lie completely flat on her back while auscultating. Instruct the woman to bend her knees and flex her hips.
Correct response: Palpate the mother's radial pulse at the same time. Explanation: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.
The nurse notes that the client has a moderate amount of bleeding after birth. Which instruction is anticipated to control bleeding? Have the client bear down to expel any clots. Put the newborn to the breast to suck. Provide intravenous clotting factors. Do nothing as this is normal after delivery.
Correct response: Put the newborn to the breast to suck. Explanation: Allowing the baby to suck on the breast stimulates oxytocin release which helps the uterus to contract and control bleeding. Having the client bear down encourages bleeding. Clotting factors are not given to the client as it could cause clot formation. Some bleeding (lochia rubra) is normal after birth; however, the bleeding is controlled.
Which statement is true regarding analgesia versus anesthesia? Analgesia and anesthesia perform the same function when it comes to blocking pain. Increased FHR variability is a common side effect when regional anesthesia is used. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Hypertension is the most common side effect when systemic analgesia is used.
Correct response: Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Explanation: Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize? Past obstetrical history Fetal status Signs that birth is imminent Client's temperature
Correct response: Signs that birth is imminent Explanation: The priority is to establish the imminence of the birth, then the fetal status. The obstetrical history can wait until after the birth of the baby, if necessary. The maternal blood pressure is a higher priority over the temperature to rule out possible preeclampsia.
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? Use a birthing ball and find a position of comfort. Stay low on her back to ease the back pain. Use the Valsalva maneuver for effective pushing. Ask for privacy, and have just the partner present.
Correct response: Use a birthing ball and find a position of comfort. Explanation: 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.
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Urinalysis Vaginal examination Leopold maneuver Nonstress test
Correct response: Vaginal examination Explanation: A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: acupressure. patterned breathing. therapeutic touch. effleurage.
Correct response: effleurage. Explanation: Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.
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 shallow deceleration occurring with the beginning of contractions variable decelerations, too unpredictable to count fetal baseline rate increasing at least 5 mm Hg with contractions fetal heart rate declining late with contractions and remaining depressed
Correct response: fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. narcotic medication to maternal client fetal movement fetal distress uteroplacental insufficiency maternal fever
Correct response: fetal movement fetal distress uteroplacental insufficiency maternal fever Explanation: An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency. Narcotics would lead to fetal bradycardia.
