Chapter 8, 9, & 10 Review Questions
A nurse is caring for an adolescent in labor an hour after she admitted to the birthing unit. The adolescent is anxious and tense. She cries during contractions and asks the nurse for epidural anesthesia. The nurse obtains the adolescent's current vital signs and reviews her history and admission information. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply.
Perform a baseline vaginal examination Tell the adolescent what to expect with each procedure Identify risk factors that contraindicate epidural anesthesia
At a prenatal visit a client who is at 36 weeks gestation states that she is having uncomfortable irregular contractions. What should the nurse recommend?
Walk around until they subside
Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?
Blowing
A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?
Cervix is dilated
A nurse is caring for a client who is having a prolonged labor. The client is annoyed and very concerned because her labor is deviating from what she perceives as normal. After the nurse has acknowledged the client's feelings, what is the next best intervention?
"I'll rub your back, and tell me if it helps"
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Auscultating the fetal heart
What position should the nurse teach a client to avoid when the client is experiencing back pain during labor?
Sims
A woman in labor hears the health care provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond?
"A vaginal birth is possible"
A client arrives in the birthing room with the fetal caput emerging. What should the nurse tell the client to do during a contraction?
"Use the panting-breathing pattern"
A pregnant client is now in the third trimester . The client tells the nurse " I want to be knocked out for the birth." How should the nurse respond?
"You don't want to be awake during the birth"
During labor, a nurse identifies that there is an early fetal heart rate deceleration. How many fetal heartbeats per minute were there early in the contraction that indicated to the nurse that the deceleration occurred.
100 to 120
A nurse is observing a reading on the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression?
Abrupt decreases in fetal heart rate that are unrelated to the contractions
A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit,which nursing action is appropriate?
Adjust the dial on the unit until the client states the pain is relived
When monitoring the FHR of a client in labor the nurse identifies an elevation of 15 beats more than the baseline rate of 135 beats/min lasting for 15 seconds. How should the nurse document this event?
An acceleration
A laboring client reports low back pain. What should a nurse recommend to the client's coach that will promote comfort?
Apply pressure to her back during contractions
A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and 3 cm dilated. The fetal head is at +1 station. In what area of the client's pelvis is the fetal occiput?
Below the ischial spines
After performing Leoplod maneuvers on a laboring client a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones?
Below the umbilicus on the right side
How does the nurse identify true labor as opposed to false labor?
Cervical dilation is progressive
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. A nurse observes variable deceleration in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?
Change the client's position
In childbirth classes, the nurse is teaching paced breathing techniques to use during labor. In which order should the breathing techniques be used as labor progresses?
Cleansing breaths Slow, deep breaths Modified- paced breathing Pant- blow breaething Slow, exhalation pushing
A client and her partner are working together during the woman's labor. The client's cervix is now dilated 7 cm, and the presenting part is low in the mid pelvis. What should the nurse instruct the partner to do that would alleviate the client's discomfort during contractions?
Deep breathe slowly
A nurse is caring for a primigravida during labor What does the nurse observe that indicates birth is about to take place?
Perineum begins to bulge with each contraction
A nurse is caring for an obese client in early labor. The anesthesiologist discussed several types of analgesia/anesthesia with the client and recommended one. The client request clarification before signing the consent form. Which type did the anesthesiologist recommend?
Epidural anesthesia
During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea and her skin becomes pale and clammy. What is the nurse's immediate reaction?
Epidural anesthesia
A nurse has just finished receiving how anesthesia will be used during a vaginal birth for a client with class I heart disease. What type of anesthesia does the client discuss that indicates to the nurse that the teaching was effective?
Epidural regional
A client in active labor has an external monitor in place. Using the monitor strip below identify the correct assessment.
FHR baseline at 150 beats/min
Why should a nurse teach pregnant women the importance of conserving the "spurt of energy" before labor?
Fatigue may influence the need for pain medication
How should a nurse direct care for a client in the transition phase of the first stage of labor?
Help the client to maintain control
What is a common problem that confronts the client in labor when an external fetal monitor has been applied to her abdomen?
Intrusion on movement
A nurse applies an ice pack to a client's back for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment?
Local anesthesia
A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her breath care provider?
Membranes rupture or contractions are 5 to 8 minutes apart
A nurse is caring for a primigravida during labor. At 7 cm dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?
Meperidine Hydrochloride
An external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction the fetal heart rate decelerates as the contraction peaks. What should the nurse do next?
Monitor the fetal heart rate until it returns to baseline when the contractions ends
A client in labor begins to experience contractions 2 to 3 minutes apart that last about 45 seconds. Between contractions the nurse identifies a fetal heart rate of 100 beats/min on the internal fetal monitor. What is the next nursing action?
Notify the health care provider
A nurse is caring for a client in labor. What client response indicates that the transition phase of labor probably has begun?
Perspires and has a flushed face
What does a nurse consider the most significant influence on many clients perception of pain when interpreting findings from a pain assessment?
Previous experience and cultural values
A client in active labor becomes very uncomfortable and asks a nurse for pain medication Nalbuphine is prescribed. How does this medication relieve pain?
Produces Amnesia
A client is admitted to the birthing unit on active labor. What should the nurse expect after an amniotomy is performed?
Progressive dilation and effacement
A primigravida who is at 40 weeks gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm dilation and the presenting part at - 1 station. After obtaining the fetal heart rate (FHR) and maternal vital signs should the nurse do next?
Provide the client with comfort measures used for women in labor
A client in the active phase the first stage of labor begins to tremble, becomes very tense during contractions, and is quire irritable. She frequently states "I cannot stand this a minute longer" What does this behavior indicate to the nurse caring for her?
She is entering the transition phase of labor
The fetus of a client in labor is assessed to be at - 1 station. Where did the nurse locate the fetus's head?
Slightly above the ischial spines
A client in active labor is admitted to the birthing room. A vaginal examination reveals the cervix to be 7 cm dilated. On the basis of this finding, what does the nurse expect the client to exhibit?
Strong contractions with intervals of several minutes
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while this monitor is in place?
The most comfortable position can be assumed
A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored?
The machinery may be frightening to a laboring couple
A nurse assesses the frequency of a client's contractions by timing them from the beginning of a contraction until when?
To the beginning of the next contraction
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client states that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered?
Transition
At 38 weeks gestation a client is admitted to the birthing unit in active labor and an external fetal monitor is applied. Late fetal heart rate declarations begin to appear when her cervix is dilated 6 cm, with contractions occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late declarations?
Uteroplacental insufficiency
During labor, a client has an internal fetal monitor applied. What fetal heart rate should most concern the nurse?
Varies from 130 to 140 beats per minute