Intrapartum

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?

"I respect your preference, whether it is to have medication or not."

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make?

"It is needed to counteract hypotension"

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?

10:30 a.m.

When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every:

15 to 30 minutes

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:

7.15 or less.

Which FHR variability is typically caused by fetal acidemia?

Absent/minimal variability

A laboring woman is admitted to the labor and birth suite at 6 cm dilation. She would be in which phase of the first stage

Active

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?

Ambulation ad lib

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

Ask the woman to describe why she believes that she is in labor.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

Cervix

A nurse is caring for a client who is 40 weeks gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first?

Check FHR

A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

Determine if the client is in true or false labor.

The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate?

Document this as indicating a normal pattern.

Identify the fetal heart rate interpretation.

Early decelerations

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready.

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?

Have the client ambulate in the hall and recheck.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage

A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing?

Meconium aspiration

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.

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?

Practicing effleurage on the abdomen

A nurse is caring for a client in the third stage of labor. Which of the following findings would not indicate placental separation?

Softening of the lower uterine segment

When managing a client's pain during labor, nurses should:

Support the client's decisions and requests

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

The frequency of the contractions is every 5 minutes.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?

These contractions help in softening and ripening the cervix.

The shortest but most intense phase of labor is the:

Transition phase

A client calls a provider's office and reports having contractions for 2 hours that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing?

True contractions

When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing?

Wait until you feel the urge to push.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR

The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare?

cephalic presentation using preprinted materials in the client's language

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

fetal position

By the end of the second stage of labor, the nurse would expect which of the following events? The

fetus is born and on mother's chest

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

increase even if relaxing and taking a shower

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

increased risk of infection

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

instruct the client or her partner to perform light fingertip repetitive abdominal massage.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client?

sacral counterpressure

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up towards the face

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations

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?

Assess the amount of cervical dilation

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take?

Assist the client into the left-lateral position

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 FHR

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?

Fetal lie

A nurse is caring for a client having contractions every 8 minutes that are 30 to 40 seconds in duration. The client's cervix is 2 cm. dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/minute. Which of the following stages and phases of labor is this client experiencing?

First stage, latent phase

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?

Intermittent fetal heart rate auscultation

Identify the fetal heart rate interpretation.

Late decelerations

Physiologic preparation for labor would be demonstrated by:

Lightening, whereby the fetus drops into true pelvis

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

The client who is very restless and is moving around in the bed

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

longitudinal