Chapter 19 OB

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include which actions? Assess for progress in labor. Supervise showers during true labor.

446

Which test is performed to determine if membranes are ruptured? Fern test

B 434

When performing vaginal examinations on laboring women, the nurse should be guided by what principle?

Cleanse the vulva and perineum before and after the examination as needed.

Which characteristic is associated with false labor contractions?

Decrease in intensity with ambulation

Which parameter should be closely monitored in a patient during the latent phase of the first stage of labor?

Fetal heart rate

What intervention does the nurse provide during the birthing process to ensure the safety of the mother and the fetus? Monitor the client's emotional and physiologic responses.

The nurse should monitor the client's emotional and physiologic responses during the birthing process to ensure the safety of mother and fetus. This helps with effective individual coping related to the birthing process. Providing ongoing feedback to the client and her partner helps decrease anxiety and enhance participation in birthing process. PG 448

During the labor process, the primary health care provider instructs the client to maintain a side-lying position before birth. What is the reason behind this instruction?

To decrease tension on the perineum

While assessing the fundus of a postpartum client, the nurse places both hands, one over the other, on the client's abdomen and applies a downward pressure toward the vagina. What are the rationales behind this intervention?

To determine whether the fundus is firm To assist the client in expelling clots

A client has been laboring for several hours and after checking the client's cervix, the nurse finds the client's cervix is dilated 9 cm and is having strong uterine contractions (UCs) each lasting for 45 to 90 seconds. Based on these observations, the nurse determines that the client is in which stage of labor?

Transition phase of the first stage of labor. PG 436

A client who is at 30 weeks gestation reports a brownish cervical discharge. What questions does the nurse ask first in order to identify the cause of the discharge?

"Did you have sexual intercourse in the last two days?" 434

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's best response?

"It's normal to be anxious about labor. Let's discuss what makes you afraid."

What instructions does the nurse give to reduce the risk of urinary retention in a client during labor? Assist the client with techniques to help stimulate voiding.

4 pg 448

A pregnant client who is full term has a cervical dilatation of 2 cm. The nurse asks the client to get admitted the next day, but after talking to the client, the nurse allows the client to be admitted the same day. What are the reasons for admitting the client in the latent stage of labor? The client lives far away from the birth center. The client had rapid labors in the past two deliveries. The client is a single mother and has no other family.

431

What should be included in the birth plan? Presence of birth companions and the role each will play Cultural and religious requirements related to the care of the mother, newborn, and placenta Labor activities such as preferred positions for labor and birth, ambulation, birth balls, showers and whirlpool baths, oral food and fluid intake Labor and birth medical interventions such as pharmacologic pain relief measures, intravenous therapy, electronic monitoring, induction or augmentation measures, and episiotomy Care and handling of the newborn immediately after birth such as immediate skin-to-skin contact, cutting of the cord, eye care, and breastfeeding

435

What are signs of potential complications of labor? Contractions lasting 90 seconds or longer Irregular fetal heart rate (FHR); suspected fetal arrhythmias More than five contractions in a 5-minute period Relaxation between contractions lasting shorter than 30 seconds Intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC])

444

What happens during the second stage of labor? The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of this stage of labor is 50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous women.

454

While caring for a client in labor, the nurse cleans the client's teeth with an ice-cold wet washcloth. What is the rationale behind the intervention? To refresh the mouth To reduce the feeling of thirst To counteract dry mouth

A client in labor may not be able to take care of her oral hygiene. Therefore, the nurse should use an ice-cold wet washcloth to clean the client's teeth to maintain oral hygiene and refresh the mouth. The pregnant client may feel thirsty due to active labor. Cleaning the client's teeth with an ice-cold wet washcloth may moisten the oral cavity and reduce the feeling of thirst. This intervention also prevents the oral cavity form becoming dry. 446

What behavior does the nurse expect in a client who is in the transition phase during the first stage of labor? The client vomits.

A client in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The client may hyperventilate, resulting in nausea and vomiting. p. 436

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's best response? "It's normal to be anxious about labor. Let's discuss what makes you afraid."

B. pg 430

The nurse is caring for a pregnant client whose cervix has dilated to 5 cm and the membranes have ruptured. What assessments does the nurse perform to prevent complications during childbirth? Body temperature every 2 hours Blood pressure and pulse every 30 minutes Presence of vaginal show every 15 minutes

Cervical dilatation of 5 cm along with ruptured membranes indicates that the client is in the active phase of the first stage of labor. Because the membranes have ruptured, the nurse should assess the client's body temperature every 2 hours, because elevated body temperature may indicate sepsis. Vital parameters such as blood pressure, heart rate, and respiratory rate should be recorded every 30 minutes. Changes in these parameters could indicate cardiopulmonary instability. The nurse should assess for vaginal show every 15 minutes to determine the progress of labor. 438

The nurse is caring for a Chinese client who is in labor. Which behavior by the client is inconsistent with common Chinese cultural practices? The client is extremely anxious during the labor

Chinese women are often stoic during labor and are typically able to withstand higher thresholds of pain. Extreme anxiety during labor is not a characteristic behavior of Chinese women. 437

The nurse says, "You are doing so well; do it again" to a client during the second stage of labor. Why did the nurse say this? To encourage the client to feel confident

During the second stage of labor, the client experiences severe pain, fear, anxiety, and confusion. The client might scream during the active pushing stage. Therefore, nurse encourages the client to feel confident in her body. 459

The nurse is assisting the primary health care provider during a client's vaginal delivery. Which nursing intervention is performed to reduce the extent of vaginal or perineal lacerations? Applying gentle pressure toward the client's vagina

During vaginal delivery, the client may sustain deep vaginal and perineal lacerations. Though lacerations cannot be prevented during fetal birth, the extent of the lacerations can be reduced. Fetal birth occurs as the fetal head is rapidly expelled from the vagina. The pressure produced during the sudden fetal birth results in deep vaginal and perineal lacerations. Therefore, the flat side of the hand is placed on the exposed fetal head and gentle pressure is applied toward the vagina. This prevents the fetal head for popping out, and prevents lacerations. PG 456

Which nursing intervention is useful for a client in labor to reduce intrathoracic pressure and prevent fetal hypoxia?

Encourage the client to exhale, holding her breath for short periods.

The nurse is assisting a client during the active phase of the second stage of labor. The nurse finds that the client has a sudden, significant increase in dark red bloody show. What does the nurse infer from this observation? The discharge indicates that the fetal head is about to deliver.

In a normal vaginal delivery, the fetus head is born first. The passage for childbirth gets stretched as the fetal head descends down, resulting in increased dark red bloody show. Therefore, a significant increase in dark red bloody show indicates the birth of the fetal head. 456

In a variation of rooming-in, called couplet care, the mother and infant share a room and the mother shares the care of the infant with whom? The nurse

In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. This may also be known as mother-baby care or single-room-maternity-care. pg 468

A client has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail?

It is a crucial time for mother and newborn. The fourth stage of labor includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members. 468

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? Squatting

Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. 451

Which is one of the best positions in which to place the mother in case of complications during delivery?

Lithotomy position

After performing the Leopold's maneuver on a client at 38 weeks of pregnancy, the nurse concludes that the client will require external cephalic version for having a vaginal delivery. What was the finding during assessment? The fetus is in the breech presentation

PG 440

While caring for a client in labor, the nurse regularly assesses the client's vital signs and fetal heart tones. Why is it important for the nurse to share this information with the client as the labor progresses? To increase the client's sense of control and lessen her fear

PG 477

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes what? The placenta has separated

Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. 456

The nurse is assisting a client during the second phase of labor. Which behavior from the client signifies the active pushing stage of the second phase of labor? The client is inattentive to the nurse's instructions.

The active stage is the pushing stage of labor, in which the client experiences severe pain and tries to push the fetus with all her effort. The client is inattentive to the nurse and directs all her concentration on childbirth PG 454

A pregnant woman who is in the first stage of labor has a body weight of 73 kg. While reviewing the medical reports, the nurse finds that the client's prepregnant body weight was 53 kg. What does the nurse interpret about the client? The client has an increased risk of caesarean delivery.

The client has an increased risk of caesarean delivery. The client has gained 20 kg over the 9 months of pregnancy. Weight gain of more than 16 kg during pregnancy indicates that the client is at high risk of cephalopelvic disproportion, and may require a caesarean delivery. PG 432

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? Encourage skin-to-skin contact of mother and baby.

The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. 445

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. What measures are included? Encouraging the woman to try various upright positions, including squatting and standing.

Upright positions and squatting may enhance the progress of fetal descent. 445

After reviewing the urinalysis reports of a pregnant client, the nurse finds that the patient has preeclampsia. What did the nurse find in the client's urinalysis report? protein

Urinalysis of the patient during pregnancy helps to assess the client's health. The presence of proteins in the urine indicates that the client may have complications, such as preeclampsia. 444

What instructions does the nurse give a client to ensure fetal safety during the second stage of labor?

"Push when you feel the urge." p. 448

What instructions does the nurse give to reduce the risk of urinary retention in a client during labor? Assist the client with techniques to help stimulate voiding.

p. 447

The nurse is assisting the primary health care provider during the labor process. Which lacerations does the nurse expect in a client who has suffered perineal lacerations? Vaginal lacerations

A laceration is an irregular tearing of tissues during childbirth. Because the perineum lies below the vagina, lacerations to the perineum may also affect the vagina. 465

A client has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail? It is a crucial time for mother and newborn. The fourth stage of labor includes delivery of the placenta. The fourth stage of labor includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize.

A,C,D,E 468

The nurse is reviewing the physical assessment data of a client in the fourth stage of labor. Which immediate intervention does the nurse provide after reviewing the data?

Assist the client to void spontaneously. 469

A client who is at 30 weeks gestation reports a brownish cervical discharge. What questions does the nurse ask first in order to identify the cause of the discharge? "Did you have sexual intercourse in the last two days?"

C. 434

What are the differences between true and false labor? In true labor, contractions occur regularly, become stronger, last longer, and occur closer together; they are usually felt in the lower back; the vaginal exam shows softening, effacement, and dilation by appearance of bloody show; and the fetus becomes engaged in the pelvis. In false labor, contractions occur irregularly; they can be felt in the back or abdomen; the cervix may be soft, but there is no effacement or dilation; and the fetus is not engaged in the pelvis.

D 431

A client sustained perineal lacerations involving the anterior rectal wall during childbirth. What is the severity of the client's perineal laceration? Fourth degree

D 465

Under which circumstance would a nurse perform a vaginal examination on a client in labor?

On admission to the hospital at the start of labor On maternal perception of perineal pressure or the urge to bear down When membranes rupture

A client sustained perineal lacerations involving the anterior rectal wall during childbirth. What is the severity of the client's perineal laceration? fourth degree.

Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. Lacerations that also involve the anterior rectal wall are classified as fourth degree.

The nurse is performing Leopold's maneuver in a client who is in the first stage of labor. What information does the nurse obtain while performing these maneuvers?

The fetal part in the fundus The presenting part of the fetus The descent of the fetus into the pelvis

If a woman complains of back labor pain, what is the best suggestion by the nurse? Lean over a birth ball with her knees on the floor

The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. 451