Chapter 16 - Labor & Delivery
Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply.
rocking back and forth with foot on chair walking with partner support straddling with forward leaning over a chair
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status
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 client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (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.
The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase?
increment
During active labor, the nurse observes the client crying during contractions and not using breathing techniques learned during prenatal classes. Which client concern is the priority for the nurse to address at this time?
ineffective breathing pattern
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?
Massage the woman's back.
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?
pain from the dilation (dilatation) or stretching of the cervix
A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse?
"Did your water break? Do you feel the baby moving?"
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:
1 cm above the ischial spines.
Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH?
7.2
A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural?
Administer a fluid bolus through the IV line to reduce the risk of hypotension
A pregnant client planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor?
Any medication should have maximum effect for the client and minimal effect on the fetus.
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman.
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?
Check the chart for the last void.
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.
All of the following are premonitory signs of labor except: lightening. effacement. bloody show. nesting. Chadwick sign.
Chadwick sign
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?
Continue to monitor the client and the fetal heart rate..
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?
Continue with the admission assessment
In which manner is the fetal status best assessed during the active and transition stages of labor?
Fetal heart rate at the peak of a contraction
A client in labor receiving epidural anesthesia develops hypotension. What would the nurse do first?
Give an intravenous bolus of fluid.
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?
Help the client regain control of her breathing technique.
The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?
Initiate comfort measures.
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.
The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension?
Priming tubing for initiating a fluid bolus
Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first?
Raise the client's legs.
A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response?
Spinal headache is not a usual complication of epidural blocks."
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?
The client reports back pain, and the cervix is effacing and dilating.
A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group, the nurse determines that the teaching was successful based on which statement by the group?
The pelvic outlet is associated with the true pelvis.
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best?
Use distraction therapy
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
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.
Vaginal rugae stretch and smooth out. The cervix dilates to 10 cm. The cervix softens.
When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?
You have no trouble walking around and using the bathroom after you receive the epidural."
Immediately after birth, the nurse shows the mother a part of the skull appearing as a diamond-shaped area which closes by approximately 18 months after birth? The nurse refers to this area as which of the following?
anterior fontanel (fontanelle)
When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?
between the umbilicus and the symphysis pubis
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
bloody show backache lightening
The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part?
buttocks
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point?
counterpressure against the sacrum
When entering the second phase of labor, a client tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the client at this time?
decisional conflict related to the use of analgesia during labor
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:
descent, flexion, internal rotation, extension, external rotation, expulsion
A nurse is caring for a woman in labor and understands that as the fetus travels through the birth canal, the fetus makes positional changes that occur concurrently. Based on the nurse's conceptualization of their sequential occurrence, list the cardinal movements of labor in the correct order that the nurse would expect the fetus to move. All options must be used.
engagement flexion internal rotation extension expulsion
A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess?
fetal anomalies
A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?
fetal back
A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. The nurse determines the session is successful when the students correctly place the following events in which order? All options must be used.
flexion internal rotation extension external rotation expulsion
A nurse is caring for a client in her fourth stage of labor. Which nursing action(s) is essential during the fourth stage of labor? Select all that apply.
fundal assessment every 15 minutes assessment of bleeding for expulsion of placental fragments
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?
head flexed forward so much that the chin touches the sternum
A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply.
internal rotation descent flexion
A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?
is narrow transversely
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
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?
just before birth
A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply.
latent active transition
A client is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this client?
latent phase
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?
less anxiety
A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?
part of the fetal body entering the maternal pelvis first
Which pelvic measurement is most important for the acceptance and entrance of the fetal head during labor?
pelvic inlet
When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?
platypelloid
A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?
poorly ossified bones of the cranial vault
The nurse is admitting a client who has just arrived stating she is in labor. Which fetal assessments will the nurse prioritize on the initial vaginal examination? Select all that apply.
presentation position attitude
The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions?
the interval between the beginning and the end of one contraction
The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with:
the powers.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?
transition phase
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
upright
