Intrapartum Care
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?
"She is in active labor; she is progressing at this point and we will keep you posted."
Which nursing action has a negative effect on fetal descent?
Administering narcotic pain medication
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
Assess for labor progression.
When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications?
Be sure to monitor fetal movements daily.
The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain
How does a woman who feels in control of the situation during labor influence her pain?
Feelings of control are inversely related to the client's report of pain.
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
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.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?
Uterine rupture
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?
acme
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
administer oxygen by mask.
A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?
brachial plexus assessment
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes
As a woman enters the second stage of labor, which would the nurse expect to assess?
feelings of being frightened by the change in contractions
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant.
A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared?
need for someone to control the situation
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate?
providing a comfortable environment with dim lighting
On examination, the nurse determines the client is at 50% effacement. This means:
the cervical canal is 1 cm long.
A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?
tocolytic therapy
A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?
transverse lie
Which assessment findings indicate a distressed fetus? Select all that apply.
Absent accelerations Late deceleration patterns Persistent bradycardia
Which client outcome during active and transitional labor is best?
The client will practice breathing techniques during contractions.
The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus. Use all options.
Cramping in the lower abdomen Pain noted in the lower back, buttocks and thighs Intense contractions resulting in fetal movement Burning in the perineum
The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which?
The fetus is in the true pelvis and engaged.
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?
increased white blood cell count
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?
"It distracts your brain from the sensations of pain."
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.
Administer oxygen by mask. Assess client for underlying causes. Turn the client on her left side.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
Change the position of the client.
Before calling the primary care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?
Check for a full bladder.
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.
At what time is the laboring client encouraged to push?
When the cervix is fully dilated
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate
Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement?
8 to 10 cm
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?
"The baby is coming. I'll explain what's happening and guide you."
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged."
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
Complete cervical dilation and time of fetal birth
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?
Fetal heart tones
A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?
It helps to rotate fetus in a posterior position.
The nurse is assessing a multipara client at 28 weeks' gestation who may be experiencing labor. Which findings should the nurse prioritize?
Positive fetal fibronectin
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?
Take no extra measures; prepare for a standard labor.
A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement?
The parents are beginning to demonstrate positive grieving behaviors.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?
dilation of cervix diameter to 10 cm
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage.
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?
external electronic fetal monitoring
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.
increase in blood pressure increase in respiratory rate increase in heart rate
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 nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?
relaxin
A woman in labor is receiving oxytocin. Which effect would the nurse need to be alert for potentially occurring?
water intoxication
