intrapartum exam 4 OB
A nurse is evaluating the external fetal monitor tracing shown. Which nursing intervention would follow? Notify the health care provider. Offer comfort measures. Administer oxygen. Turn client to the left side.
Offer comfort measures. Explanation: It is important for the nurse to evaluate the monitor tracings and interpret fetal well-being. The monitor tracings are interpreted as early decelerations. At this point, the nurse will continue to monitor and offer comfort measures.
Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply. Effleurage Massage Pain medication Hypnosis Patterned breathing Acupressure
Patterned breathing Hypnosis Pain medication Massage Acupressure Explanation: Depending upon the client's labor plan and the preparation she and her partner have received prior to the labor experience, patterned breathing, hypnosis, pain medication, massage and acupressure are all options to improve relaxation and pain management. Effleurage is also a technique used in pain management; however, it is only used in the early phase of labor.
A woman at 40+ weeks' gestation is attending a clinic visit where the health care provider suggests they "strip the membranes" to hasten the start of labor. The clinic nurse should inform the woman to watch for and report which potential complication following this procedure? Select all that apply. leaking of clear fluid from the vagina foul-smelling vaginal discharge noted on panties onset of a precipitous birth bleeding from low placenta backache from pulled muscle
bleeding from low placenta leaking of clear fluid from the vagina foul-smelling vaginal discharge noted on panties Explanation: Possible complications following "stripping the membranes" include bleeding from an undetected low-lying placenta, inadvertent rupture of membranes (clear fluid leaking from vagina), and the possibility of infection (foul-smelling vaginal discharge) if membranes should rupture.
A woman has been in active labor for over 20 hours, and the nurses are discussing this case with the health care provider. The nurses know to assess this woman for which potential complication from a prolonged labor? Select all that apply. premature rupture of membranes exaggerated pain exhaustion maternal postpartal infection bleeding tendencies to the point of hemorrhage
bleeding tendencies to the point of hemorrhage maternal postpartal infection Explanation: The risk of maternal postpartum infection, hemorrhage, and infant mortality is higher in women who have a prolonged labor than in those who do not. Therefore, it is vital to recognize and prevent dysfunctional labor to the greatest extent possible. In active labor, it is likely the membranes have already ruptured. Exhaustion occurs following labor and is not specific to prolonged labor. All labor results in pain, not just prolonged labor.
A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply. contractions every 1 to 2 minutes cervical effacement of 90% strong desire to push contractions lasting up to 60 seconds cervical dilation (dilatation) of 6 cm
cervical dilation (dilatation) of 6 cm contractions lasting up to 60 seconds Explanation: During the active phase, the cervix usually dilates from 4 to 7 cm, with 40% to 80% effacement taking place. Contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). A cervical effacement of 90% and a strong desire to push signify the transition phase.
A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? Select all that apply. hyperglycemia cyanosis arrhythmia pulmonary edema hematuria
cyanosis pulmonary edema Explanation: The nurse should monitor cyanosis and pulmonary edema when caring for a client with amniotic fluid embolism. Other signs and symptoms of this condition include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest. Arrhythmia, hematuria, and hyperglycemia are not known to occur in cases of amniotic fluid embolism. Hematuria is seen in clients having uterine rupture.
During a prepared childbirth class, the nursing is discussing the differences between true and false labor. Which responses by a client indicate an understanding of false labor? Select all that apply. "Walking will make my labor pains increase if I am experiencing false labor." "Vaginal pressure may intensify during false labor." "Maintaining hydration by drinking water will lessen false labor pains." "The intensity of contractions is inconsistent in false labor." "False labor pains begin in the back and move downward toward the pelvis.
"Maintaining hydration by drinking water will lessen false labor pains." "The intensity of contractions is inconsistent in false labor." Explanation: False labor is a phenomena that occurs in the later weeks of pregnancy. During false labor, the woman may experience contractions. These contractions may vary in intensity. They do not become regular nor do they increase in intensity. Activity such as walking can increase contraction strength and frequency during true labor, but walking does not increase the manifestations of false labor. Remaining hydrated is important. Dehydration may result in uterine irritability and false labor pains. False labor pains are felt in the abdomen; in contrast, true labor contractions begin in the back and radiate to the front of the abdomen. Pelvic pressure increases during true labor.
A birth room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48 mm Hg, pulse rate 150 bpm, and mucous membranes are pale. Which interventions should be the priority for the nurse? Select all that apply. Discontinue the IV oxytocin infusion. Apply oxygen mask at 10 L/min. Assist the provider in pulling harder on the placenta to get it removed quicker. Give the provider assistance by helping reinsert the uterus back through the cervical opening. Call environmental services to mop up the blood.
Apply oxygen mask at 10 L/min. Discontinue the IV oxytocin infusion. Explanation: Because uterine inversion occurs in various degrees, the inverted fundus may lie within the uterine cavity or the vagina, or in total inversion, it may protrude from the vagina. An IV fluid line should be inserted if one is not already present (use a large-gauge needle). If a line is already in place, open it to achieve optimal flow of fluid to restore fluid volume. The nurse should administer oxygen by mask and assess vital signs. Oxytocin, if being used, should be discontinued because it makes the uterus more tense and difficult to replace. The nurse should never attempt to replace an inversion because handling of the uterus could increase the bleeding. The nurse should never attempt to remove the placenta if it is still attached because this would create a larger surface area for bleeding. Blood on the floor is a very low priority at this time.
During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. Document events in the record. Lower the head of the bed. Administer oxytocin to increase the contractions. Keep time. Assist with maneuvers.
Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed. Explanation: The nurse will assist with the maneuvers used to facilitate birth of the shoulders. The nurse also keeps time, by calling out how much time has passed, since the head was delivered. The fetus needs to be completely birthed within 5 minutes to minimize the risk of hypoxia. Documentation of the events taking place, including the use of maneuvers and maternal and fetal response, is another nursing responsibility. The head of the bed needs to be lowered to a flat position to increase the effectiveness of McRoberts maneuver and to give the health care provider the maximum space to birth the shoulders. Oxytocin is not administered in this situation. The shoulders are stuck, and making the contractions stronger will not resolve the problem but will increase fetal distress.
A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply. CBC U/A thyroid level amniotic fluid analysis arterial blood gases
CBC U/A amniotic fluid analysis Explanation: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.
A client arrives at the clinic in labor. The nurse assesses a bulging perineum and prepares for the birth. Place the nurse's actions in sequence. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Deliver the head 2Call for assistance 3Put on gloves 4Palpate for a nuchal cord 5Use bulb to suction mouth and nose 6Support perineum with one hand
Call for assistance Put on gloves Support perineum with one hand Deliver the head Palpate for a nuchal cord Use bulb to suction mouth and nose Explanation: The nurse assesses a bulging perineum noting that birth is imminent. The nurse would call for assistance, put on gloves, support the perineum, deliver the head, palpate for a nuchal cord, and use bulb to suction mouth and nose.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation? Perform a vaginal examination to assess cervical dilation (dilatation) and effacement. Administer oxygen after turning the client on her left side. Continue to monitor the fetal heart rate because this pattern is benign. Stay with the client while reporting the finding to the health care provider.
Continue to monitor the fetal heart rate because this pattern is benign. Explanation: Early decelerations are a benign finding and not indicative of fetal distress. They do not require intervention; therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal examination, report the finding to the health care provider nor administer oxygen at this time.
The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Confirm presentation. 2Determine position. 3Determine presentation. 4Determine attitude.
Determine presentation. Determine position. Confirm presentation. Determine attitude. Explanation: Leopold's maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. With the woman in the supine position, perform the first maneuver to determine presentation. The second maneuver determines position. The third maneuver will confirm presentation. The fourth maneuver is performed to determine the attitude of the fetus.
The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply. Blood pressure: 120/78 mm Hg Heart rate: 82 bpm Pulse oximeter: 95% Fetal heart rate 198 bpm Urine output: 20 ml/hr
Fetal heart rate 198 bpm Urine output: 20 ml/hr Explanation: Assessment parameters of hemodynamic stability include heart rate, blood pressure within normal limits, urine output greater than 30 ml/hr, and continuous fetal heart rate monitoring with a rate between 120 and 160 bpm. In this situation, the client's low urine output and high fetal heart rate are signs of being hemodynamically unstable.
A laboring woman with a history of a previous cesarean birth suddenly begins to exhibit manifestations of hypovolemic shock. Suspecting either complete or partial uterine rupture, which priority interventions should the nurse implement first? Select all that apply. Prepare to administer IV oxytocin to assist with uterine contraction. Increase IV fluids immediately. Weigh all the blood-saturated bandages to determine amount of blood loss. Prepare to administer epinephrine directly into the uterine muscle. Call respiratory therapy to obtain ABGs.
Increase IV fluids immediately. Prepare to administer IV oxytocin to assist with uterine contraction. Explanation: Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency. The nurse should administer emergency fluid replacement therapy as prescribed and anticipate the use of IV oxytocin to attempt to contract the uterus and minimize bleeding. ABGs are not the priority. Epinephrine is not given by direct injection into a muscle but by IV infusion during a code to cause vasoconstriction, thereby increasing BP. Blood loss will be estimated. Weighing saturated bandages is not the priority.
Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply. The client may begin to cry The woman is more quiet and introverted The client states an urge to push Hyperventilation may occur Irritability and restlessness may occur Increase in bloody show
Increase in bloody show The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur Explanation: During the transition phase, contractions are strong and intense. At this point the client may feel out of control and unable to go on. There may be an increase in the bloody show as delivery approaches. The client feels a burning in the perineum and an urge to push. The client may be irritable and restless and may cry. Due to patterned breathing, the client may hyperventilate. It is during the active phase of labor that the client becomes introverted and quiet.
The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which statements should she include in her presentation? Select all that apply. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. It significantly increases the risk of cesarean birth. It significantly increases the weight of the newborn.
It significantly increases the risk of cesarean birth. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. Explanation: Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented birth, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor.
A birth is complicated by shoulder dystocia. Place the procedures to resolve the shoulder dystocia in order of implementation. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Rubin maneuver 2Suprapubic pressure 3Woods' screw maneuver 4McRoberts maneuver
McRoberts maneuver Suprapubic pressure Rubin maneuver Woods' screw maneuver Explanation: During a shoulder dystocia situation, the order of procedures to correct the situation is: (1) McRoberts maneuver; (2) suprapubic pressure; (3) Rubin maneuver, and (4) Woods' screw maneuver. McRoberts maneuver involves hyperflexing the mother's legs to her abdomen. It increases mobility at the sacroiliac joint, allowing rotation of the pelvis and facilitating the release of the fetal shoulder. Next, suprapubic pressure applies pressure above the pubic bone. If that is not successful, Rubin maneuver can be used. It is a secondary, rotational maneuver to deliver the baby. Finally, the Woods' screw maneuver is attempted. In this maneuver, the anterior shoulder is pushed toward the baby's chest, and the posterior shoulder is pushed toward the baby's back, making the baby's head somewhat face the mother's rectum.
Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply. Position client on the left side throughout the labor process. Have a client remain on bed rest with bathroom privileges only. Monitor maternal and fetal vital statistics every hour. Answer questions and encourage verbalization of fears. Report an elevated temperature over 38℃ (100.4℉).
Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears. Explanation: Consider what occurs in the latent (or early phase) of the first stage of labor, which are contractions and effacement. The nursing interventions that impact maternal and fetal injury include monitoring vital statistics, reporting temperature elevation over 38℃ (100.4℉), and answering questions and encouraging client verbalization of fears. The client is often excited and talkative. The client does not need to be on bed rest or positioned on the left side unless there is a complication.
A client at 34 weeks' gestation arrives at labor and delivery after falling. The nurse writes the above notes. Based on these assessments, the nurse anticipates which plan of care for this client? Administer tocolytics to stop uterine contraction. Begin induction of labor. Perform cesarean birth immediately. Monitor maternal/fetal status for 8 hours.
Monitor maternal/fetal status for 8 hours. Explanation: The client was in distress on admission. However, over 30 minutes, both maternal and fetal status are stabilizing. Monitoring maternal/fetal status is an appropriate plan of care. An immediate cesarean delivery would be appropriate if the life or well-being of mother or fetus was in danger. Given that the client is at 34 weeks' gestation, induction of labor is not appropriate. There is no evidence of preterm labor; therefore, tocolytic therapy is not needed.
A client has had a normal labor progression after the spontaneous rupture of clear fluid at home. As the client continues to show no signs of complications, which actions should the nurse prioritize to prepare for the birth? Select all that apply. Move the newborn warmer to the birth area and turn it on. Check the functionality of the oxygen source and equipment. Document events as they are happening. Connect the meconium aspirator to the wall suction and turn it on. Open the newborn crash cart or box to ensure easy access to all supplies.
Move the newborn warmer to the birth area and turn it on. Check the functionality of the oxygen source and equipment. Document events as they are happening. Explanation: To prepare for the birth of a normal newborn in an uncomplicated labor, the nurse should ensure that there is an adequately warm area to receive the newborn. The nurse needs to ensure that oxygen and suction equipment is readily available (and functional) and must ensure that all equipment for resuscitation is available (not necessarily opened). The nurse should also make a record of the development of the labor as it progresses. A meconium aspirator is necessary only when meconium is present.
The nurse is assessing a client for rupture of membranes. Which findings would confirm the presence of ruptured membranes? Select all that apply. Ferning is present. Nitrazine paper turns blue. A pool of fluid is visible in the vagina. The client reports having wet pants. The cervix is effaced.
Nitrazine paper turns blue. Ferning is present. A pool of fluid is visible in the vagina. Explanation: The three signs to confirm rupture of membranes are visible pool of fluid in the vagina, blue nitrazine test resulting from the alkaline amniotic fluid, and ferning present on microscopic examination. The client's report of wet pants is not diagnostic of ruptured membranes. Effacement of the cervix begins prior to the onset of labor and before the rupture of membranes.
A woman has been progressing through labor uneventfully until following an intense contraction, when she develops signs of umbilical cord compression. The primary care provider can feel a portion of the cord in the vagina. Which emergency intervention should the nurse implement? Select all that apply. Place a gloved hand in vagina, put upward pressure on presenting part to keep it off the cord. Position the woman in a knee-chest position. Administer terbutaline, a tocolytic, as prescribed. Locate and insert a vacuum suction catheter into vagina and push infant back into uterus. Apply oxygen mask at 10 L/min.
Place a gloved hand in vagina, put upward pressure on presenting part to keep it off the cord. Position the woman in a knee-chest position. Apply oxygen mask at 10 L/min. Administer terbutaline, a tocolytic, as prescribed. Explanation: A prolapsed cord is always an emergency situation because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus. Management is aimed at relieving pressure on the cord. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a knee-chest or Trendelenburg position to cause the fetal head to fall back from the cord. Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve oxygenation to the fetus. A tocolytic (like terbutaline) agent may be prescribed to reduce uterine activity and pressure on the fetus. Asking the woman to bear down is contraindicated at this time.
The nurse writes the above notes upon client admission. Based on this assessment the nurse anticipates which plan of care? Prepare for an emergency cesarean birth. Artificially rupture membranes to stimulate labor. Observe for 4 hours and then discharge home. Begin oxytocin to induce labor.
Prepare for an emergency cesarean birth. Explanation: The client has a class 3 placental abruption (abruptio placentae). There are signs of fetal distress; maternal tachycardia and hypotension; low hematocrit and hemoglobin; and borderline platelet count. To save the baby and mother, the baby needs to be born immediately via cesarean birth.
The nurse is discussing options to provide relief of labor pain when the client states, "Why can't the health care provider provide a sedative during labor?" Which disadvantages are common with providing a sedative as pain management? Select all that apply. Sedatives will not provide pain relief. The client feels restless and unable to focus. Sedatives allow the client to sleep through the delivery. The sedation effect can cross to the fetus. Sedatives are only used in early labor
Sedatives will not provide pain relief. The sedation effect can cross to the fetus. Sedatives are only used in early labor Explanation: Sedatives are used in the early stage of labor to promote sleep, not restlessness. Sedation does not extend to the delivery period as other medications are used in active labor. Disadvantages of using sedatives are as follows: they do not provide pain relief, they can pass to the fetus, and they are not used throughout the labor process.
A primigravida is 1 cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which option(s) should the nurse point out to the client? Select all that apply. Sitting in a tub of warm water Simple breathing exercises Effleurage Walking and then using a birthing ball It is too late for nonpharmacologic measures.
Simple breathing exercises Effleurage Walking and then using a birthing ball Explanation: Simple breathing exercises, effleurage, walking, and using a birthing ball are all techniques which have been effective in the early stages of labor to help the client cope with the pain and avoid pain medication, especially epidurals. It is not too late to use nonpharmacologic measures and, in fact, this is the best time to use them. It is too soon for hydrotherapy and it could actually slow down the labor process. It is best if this is used after the woman has dilated to 5 cm.
A nurse is describing the events of labor to a group of pregnant women. Put the following events of labor as the nurse would explain them from first to last. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Fetus continues descent. 2Placenta separates. 3The cervix dilates to 2 cm. 4Crowning occurs. 5Cervix becomes fully effaced. 6Placenta is expelled.
The cervix dilates to 2 cm. Cervix becomes fully effaced. Fetus continues descent. Crowning occurs. Placenta separates. Placenta is expelled. Explanation: The events of labor occur in this order: 1) the cervix dilates to 2 cm, 2) cervix becomes fully effaced, 3) fetus continues descent, 4) crowning occurs, 5) placenta separates, and 6) placenta is expelled.
A client is 2 weeks past her due date, and her health care provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply. The cervix is ripe. The fetus is in a longitudinal lie. Maternal blood pressure is normal. A presenting part is engaged. Cephalopelvic disproportion is present. There is absence of eclampsia.
The fetus is in a longitudinal lie. The cervix is ripe. A presenting part is engaged. Explanation: Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin-sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.
A mother pregnant with her second baby is admitted to L&D for a vaginal birth after cesarean (VBAC). While obtaining an admission assessment, what important information is necessary for the labor and delivery nurse to obtain? Select all that apply. Reason for the cesarean birth The type of uterine incision The presenting part of the fetus The fetal heart rate The mother's vital signs
The presenting part of the fetus The type of uterine incision Reason for the cesarean birth The fetal heart rate The mother's vital signs Explanation: It is important for the health care providers to know the incision type in the uterus from the cesarean birth. If the incision is vertical, there is a high potential for uterine rupture and this is a contraindication for labor and vaginal birth. It is also important to know the reason for the previous surgical delivery because it may play a role in attempting a vaginal delivery. If the presenting part of the fetus is anything but vertical it is unlikely a vaginal delivery will be attempted. The fetal heart rate and mother's vital signs are always important. An abnormal fetal heart rate and maternal hypertension may be contraindications for a vaginal delivery.
Which assessment findings of the fetus during labor are normal? Select all that apply. Fetal heart baseline of 130 bpm Repeated variable decelerations Variability between 18-20 bpm Gradual increase in the fetal heart rate baseline Late decelerations
Variability between 18-20 bpm Fetal heart baseline of 130 bpm Explanation: Normal patterns suggest that the fetus is tolerating the labor. Both variability between 18-20 bpm and a baseline heart rate of 130 bpm are within normal limits. Both late and repeated variable decelerations are abnormal and may require further intervention. A gradual increase in the fetal heart rate baseline can signal a distressed fetus.
A pregnant client at 42 weeks' gestation is undergoing a scheduled induction of labor based on consideration of which factors? Select all that apply. abnormal fetal presentation cervical ripeness complete placenta previa fetal size gestational age
cervical ripeness fetal size gestational age Explanation: Factors that the care provider should consider when deciding if and when to induce labor include cervical ripeness, gestational age and fetal size, fetal pulmonary maturity, fetal ability to tolerate labor, uterine sensitivity to the proposed induced method, and maternal condition. The health care provider does not confirm abnormal fetal presentation and complete placenta previa when deciding to induce labor. Abnormal fetal presentation and complete placenta previa are considered contraindications to the induction of labor and not as positive factors.
The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply. maternal diabetes shoulder dystocia maternal exhaustion epidurals high fetal station at complete cervical dilation multiple gestation excessive analgesia
epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Explanation: Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffective pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation.
A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client? Select all that apply. characteristics of contractions appearance of vaginal blood estimated due date history of substance use history of drug allergy
estimated due date characteristics of contractions appearance of vaginal blood Explanation: When conducting an admission assessment on the phone for a pregnant client, the nurse needs to obtain information regarding the estimated due date, characteristics of contractions, and appearance of vaginal blood to evaluate the need to admit her. History of substance use or a drug allergy is usually recorded as part of the client's medical history.
A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply. recurrent late decelerations fetal bradycardia minimal variability fetal tachycardia sinusoidal pattern
fetal bradycardia sinusoidal pattern recurrent late decelerations Explanation: FHR patterns that are predictive of abnormal fetal acid-base status include fetal bradycardia, sinusoidal pattern, and recurrent late decelerations. Fetal tachycardia and minimal variability, although each needs evaluation and continued monitoring, are not predictive of abnormal fetal acid-base status.
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. fetal movement narcotic medication to maternal client uteroplacental insufficiency fetal distress maternal fever
fetal movement fetal distress uteroplacental insufficiency maternal fever Explanation: An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency. Narcotics would lead to fetal bradycardia.
A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? Select all that apply. massaging prescribed pain killers chewing gum acupressure hand holding
hand holding massaging acupressure Explanation: To provide comfort to the pregnant client, the nurse should make use of massage, hand holding, and acupressure to bring comfort to the pregnant client during labor. It is not advisable to provide chewing gum to a client in labor; it may cause accidental asphyxiation. Pain killers are not prescribed for a client experiencing labor.
A client in labor has been diagnosed with shoulder dystocia. Which risk factors would the nurse expect in the prenatal history? Select all that apply. dates indicating a post-term pregnancy maternal cervical insufficiency measurements indicating fetal macrosomia documented intrauterine growth restriction history of maternal diabetes
history of maternal diabetes dates indicating a post-term pregnancy measurements indicating fetal macrosomia Explanation: Shoulder dystocia is an obstetric emergency as the shoulders are stuck in the bony pelvis, preventing delivery. Risk factors of shoulder dystocia include maternal diabetes, maternal obesity, post-term pregnancy, fetal macrosomia, previous history of shoulder dystocia, and multiparity. Intrauterine growth restriction and cervical insufficiency are not the risks associated with shoulder dystocia. Intrauterine growth restriction is one of the factors that increases the risk of a breech presentation. Cervical insufficiency is a risk factor related to preterm labor.
A nursing instructor highlights which risk factors associated with preterm labor? Select all that apply. weight of pregnant mother history of previous preterm birth uterine or cervical abnormalities weight of fetus current multiple gestation pregnancy
history of previous preterm birth current multiple gestation pregnancy uterine or cervical abnormalities Explanation: The top risk factors for preterm labor include history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities. The weight of the fetus or mother does not cause preterm labor.
A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply. low socioeconomic status high level of stress infection smoking alcohol use hypertension
low socioeconomic status smoking high level of stress alcohol use Explanation: Demographic and lifestyle risk factors associated with preterm labor are extremes of maternal age (younger than 17 years or older than 35 years), low socioeconomic status, smoking, alcohol or drug use, high levels of stress, and long working hours. Infection and hypertension are medical risk factors and not demographic or lifestyle factors.
A client at 33 weeks' gestation is calling the office with various reports and is very concerned. The nurse recognizes which report(s) as indicating the client is potentially going into preterm labor? Select all that apply. general sense of discomfort irregular contractions GI upset (nausea, vomiting, diarrhea) low, dull backache achiness in the thighs
low, dull backache general sense of discomfort GI upset (nausea, vomiting, diarrhea) achiness in the thighs Explanation: There are various subtle symptoms of preterm labor that a woman may experience. They include change or increase in vaginal discharge; pelvic pressure; low, dull backache; menstrual-like cramps; feeling of pelvic pressure or fullness; GI upset; general sense of discomfort or unease; heaviness or aching in the thighs; uterine contractions, with or without pain; more than six contractions per hour; intestinal cramping, with or without diarrhea; and persistent contractions.
A nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply. indomethacin atosiban nifedipine nitroglycerin magnesium sulfate
magnesium sulfate atosiban indomethacin nifedipine Explanation: Medications commonly used for tocolysis include magnesium sulfate, atosiban, indomethacin, and nifedipine. These drugs are used "off label," meaning that they are effective but have not been officially tested and developed for this purpose by the US Food and Drug Administration (FDA).
After conducting a review class on the labor and birth process for a group of nurses working in the community clinic, the nurse determines that the teaching was successful when the group identifies which factors as affecting the labor process? Select all that apply. powers place passenger patience participation
powers passenger patience Explanation: There are "five Ps" that affect the labor process. They are passageway, passenger, powers, position, and psychological response. There are an additional five that can also have an effect on the labor process. They include philosophy, partners, patience, client preparation, and pain control.
A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply. problems with the uterus problems with the mother's diet problems with access to health care problems with finances problems with the fetus
problems with the uterus problems with the fetus Explanation: Labor dysfunction can occur because of problems with the uterus or fetus. Although the others might affect the type of prenatal care a woman receives, they do not directly affect her process of labor.
The nurse would monitor clients with which conditions for fetal demise? Select all that apply. malpresentation hypertension prolonged pregnancy multifetal gestation hydramnios
prolonged pregnancy hypertension Explanation: Prolonged pregnancy and hypertension are causes of intrauterine fetal demise in late pregnancy that the nurse should be aware of. Other factors resulting in intrauterine fetal demise include infection, advanced maternal age, Rh disease, uterine rupture, diabetes, congenital anomalies, cord accident, abruption, premature rupture of membranes, or hemorrhage. Hydramnios, multifetal gestation, and malpresentation are not the causes of intrauterine fetal demise in late pregnancy; they are causes of umbilical cord prolapse.
The assessment of a pregnant client who is toward the end of her third trimester reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? Select all that apply. myometrial contractions reduction in cervical resistance boggy appearance of the uterus hypotonic character of the bladder softening and thinning of the cervix
reduction in cervical resistance myometrial contractions softening and thinning of the cervix Explanation: Upon seeing the increased prostaglandin levels, the nurse should assess for myometrial contractions, leading to a reduction in cervical resistance and subsequent softening and thinning of the cervix. The uterus of the client will appear boggy during the fourth stage of labor, after the completion of pregnancy and birth. Hypotonic character of the bladder is also marked during the fourth stage of pregnancy, not when the prostaglandin levels rise, marking the onset of labor.
A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply. cervical dilation (dilatation) of 6 cm strong desire to push irritability with restlessness cervical effacement of 70% apprehension mixed with excitement
strong desire to push irritability with restlessness Explanation: A strong desire to push occurs most often in the transition phase of the first stage of labor. During this phase the woman commonly experiences increased apprehension and irritability with restless movements and feelings of loss of control and being overwhelmed. Cervical dilation (dilatation) from 4 to 7 cm characterizes the active phase of the first stage of labor. The woman in the early or latent phase of the first stage of labor often is filled with apprehension but is excited about the start of labor. During the active phase of the first stage of labor, cervical effacement of 40% to 80% occurs.
A nurse is preparing to teach a class to pregnant women about the signs of preterm labor and what to do if these occur. Which signs of preterm labor should the nurse include in the presentation? Select all that apply. feelings of stress nausea, vomiting, and diarrhea uterine contractions, cramping, low back pain leaking of fluid from the vagina increase in vaginal discharge feeling of pelvic pressure or fullness
uterine contractions, cramping, low back pain feeling of pelvic pressure or fullness increase in vaginal discharge nausea, vomiting, and diarrhea leaking of fluid from the vagina Explanation: Signs and symptoms of preterm labor include uterine contractions, cramping, or low back pain; feeling of pelvic pressure or fullness; increased vaginal discharge; nausea, vomiting, and diarrhea; and leaking of fluid from the vagina.
A woman in labor with a history of drug and alcohol addiction and no prenatal care has arrived in the emergency department in active labor with cervix 5 cm dilated. An ultrasound shows the fetus in a breech presentation. As a nurse prepares to care for this woman, which assessments indicate the fetus is in distress and needs immediate help to survive? Select all that apply. variable deceleration FHR pattern noted on monitor fetal heart rate decreasing into the 80s premature rupture of membranes with yellow-green color fluid that smells foul meconium staining noted on fluid seeping from vagina minimal movement as the fetus descends into the pelvic opening
variable deceleration FHR pattern noted on monitor fetal heart rate decreasing into the 80s Explanation: Variable deceleration fetal heart rate pattern noted on the monitor signifies a possible prolapsed cord. Low fetal heart rate can be a sign of hypoxia. Meconium staining occurs because of cervical pressure on the buttocks and rectum, not because of fetal anoxia, so it is not a sign of fetal distress. It is normal for the fetus to slow in movement as it makes its way through the birth canal.
A woman in labor with a history of drug and alcohol addiction and no prenatal care has arrived in the emergency department in active labor with cervix 5 cm dilated. An ultrasound shows the fetus in a breech presentation. As a nurse prepares to care for this woman, which assessments indicate the fetus is in distress and needs immediate help to survive? Select all that apply. × premature rupture of membranes with yellow-green color fluid that smells foul× variable deceleration FHR pattern noted on monitor× × × × × fetal heart rate decreasing into the 80s× meconium staining noted on fluid seeping from vagina× × × × minimal movement as the fetus descends into the pelvic opening×
variable deceleration FHR pattern noted on monitor× fetal heart rate decreasing into the 80s× Explanation: Variable deceleration fetal heart rate pattern noted on the monitor signifies a possible prolapsed cord. Low fetal heart rate can be a sign of hypoxia. Meconium staining occurs because of cervical pressure on the buttocks and rectum, not because of fetal anoxia, so it is not a sign of fetal distress. It is normal for the fetus to slow in movement as it makes its way through the birth canal.
