Intrapartum Management
The laboring client's amniotic membranes have just ruptured. Which nursing action should be priority? 1. monitor maternal temperature 2. inspect characteristics of the fluid 3. perform a sterile vaginal examination 4. assess the FHR pattern
4. assess the FHR pattern The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well-being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR.
The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural? 1. WBC: 24,000/mm3 2. glucose: 78 grams/dL 3. hemoglobin: 10.2 g/dL 4. platelets: 100,000/mm3
4. platelets 100,000/mm3 The nurse should report the low platelet count of 100,000/mm3 (normal is 150,000 to 450,000/mm3). A low count can contribute to bleeding and affect the use of epidural anesthesia.
The laboring client is at 5/100/0, ROA, and having difficulty coping with her contractions. She does not want epidural analgesia or medications. How can the nurse best assist the client and her partner? 1. apply counter pressure to sacral area with a firm object 2. implement effleurage (light massage) of the abdomen 3. provide a quiet, calm, and relaxed environment 4. reemphasize modified-pace breathing techniques
4. reemphasize modified-pace breathing techniques Breathing techniques provide distraction, reduce pain perception, and help the client maintain control during labor. The modified-paced breathing technique is usually more effective during active labor (4 to 7 cm). The client is at 5 cm. The modified-pace technique is preferred at about twice the normal breathing rate and requires that the client remain alert and concentrate fully on her breathing.
After performing Leopold's maneuvers and determining that the fetus is in the RSA position, the nurse plans to assess the FHR. Place an X on the area of the client's abdomen where the nurse would best be able to listen and count the FHR.
The RUQ of the client's abdomen is the best area to listen to and count the FHR when the fetus is in the RSA position. When the fetus is in the RSA position, the fetal back faces the client's right side. The fetal presentation is breech, and the fetal head is in the upper segment of the client's abdomen. The FHR is most clearly heard through the fetal back.
The client on the labor unit has been experiencing frequent, painful contractions for the last 6 hours. The contractions are of poor quality, and there has been no cervical change. Which interventions should the nurse implement? Select all that apply. 1. maintain bedrest 2. administer a sedative 3. administer an analgesic 4. prepare for cesarean delivery 5. prepare to start oxytocin
1, 2, 3, 5 This client is experiencing a hypertonic labor pattern in which her contractions are frequent and painful, but no cervical change has occurred. This client should be encouraged to rest often. A sedative should be given to assist the client to rest. Because the contractions are painful, an analgesic should be administer to help the client relax and cope more effectively. If the hypertonic labor pattern continues, augmentation should be initiated with either an oxytocin infusion or amniotomy.
The nurse reviews information and assesses the laboring client at 42 weeks' gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply. 1. umbilical cord prolapse 2. transverse fetal lie 3. cervical dilation not progressing 4. premature rupture of membranes 5. previous cesarean incision
1, 2, 5 Inducing labor with an umbilical cord prolapse can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP.
The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor? 1. lengthening of fetal cord 2. increased bloody show 3. a strong urge to push 4. more frequent contractions
1. lengthening of fetal cord The third stage of labor lasts from brith of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation.
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply. 1. progressive cervical dilation and effacement 2. walking usually increases contraction intensity 3. warm tub baths and rest lessen contractions 4. discomfort is usually in the client's abdomen 5. contractions increase in duration and intensity
1, 2, 5 Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor.
The nurse is caring for the low-risk client during the first stage of labor. When should the nurse assess the fetal heart rate (FHR) pattern? Select all that apply. 1. before administering medications 2. at least every 15 minutes 3. after vaginal examinations 4. during a hard contraction 5. when giving oxytocin
1, 3 The FHR may be affected by medications given to the mother. Therefore a baseline FHR should be determined before giving any medication to the laboring client and then assessed again after giving the medication. The FHR should be assessed after each vaginal examination because the fetus could change positions, or be stressed by the intrusion of the examiner's fingers, or intact membranes could have ruptured.
The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6F, and the FHR is 120 with minimal variability and no accelerations. The client's group beta streptococcus culture is positive. Which intervention should the nurse plan to implement? Select all that apply. 1. prepare for cesarean birth due to chorioamnionitis 2. start oxytocin for labor induction 3. start antibiotics as directed for the GBS infection 4. prepare the client for epidural anesthesia 5. notify the neonatologist of the client's status 6. administer a cervical ripening agent
1, 3, 4, 5 Because this client is not in labor and chorioamnioinitis is possible, a cesarean birth is indicated. The client should be given antibodies as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery.
The laboring client just had a convulsion after being given regional anesthesia. Which intervention should the nurse implement? Select all that apply. 1. establish an airway 2. position on her right side 3. provide 100% oxygen 4. administer diazepam 5. page the anesthesiologist STAT
1, 3, 4, 5 The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthesia.
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply. 1. has breakthrough sharp pain 2. blood pressure is increased 3. has a pounding headache 4. unable to feel a full bladder 5. has an elevated temperature
1, 3, 4, 5 Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is low the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidentally punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1 or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss.
The client in labor is requesting water therapy to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/-2. How should the nurse respond to the client's request? 1. "usually we initiate hydrotherapy during active labor" 2. "you will not need to change positions quite as much" 3. "we will not be able to monitor FHR as easily" 4. "you can use hydrotherapy for up to 60 minutes at a time"
1. "usually we initiate hydrotherapy during active labor" Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor? 1. an increase in maternal HR 2. a decrease in the cardiac output 3. an increase in the WBC count 4. a decrease in intravascular volume
1. an increase in maternal HR Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume.
The nurse is assessing the client who is I the active stage of labor. Which is the most crucial information that the nurse should assess related to the client's ethnicity and stage of labor? 1. choice of pain control measures 2. desire for hot or cold fluids 3. persons to be in the room during labor and birth 4. desire for circumcision if male infant is born
1. choice of pain control measures Because cultural variations exist in pain control measures used and pain tolerance, the most crucial assessment in the active stage of labor is the client's choice of pain control measures.
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride? 1. completely dilated and 100% effaced 2. FHR of 120 bpm 3. reassuring FHR variability and accelerations 4. variable decelerations with reassuring FHR
1. completely dilated and 100% effaced Systemic medications, such as nalbuphine hydrochloride, should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery.
The nurse is about to auscultate the FHR on the client in triage. What information should be determined first to find the correct placement for auscultation? 1. position of the fetus 2. position of the placenta 3. presence of contractions 4. where to apply the ultrasonic gel
1. position of the fetus The nurse should first perform Leopold's maneuvers to determine the fetal position. This will enable proper placement of the Doppler device over the location of the FHR.
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding throughout the cervix. What should the nurse do first? 1. put continuous pressure on the presenting part to keep it off the cord 2. place the bed in Trendelenburg position 3. insert a urinary catheter and install saline 4. continue to monitor the FHR
1. put continuous pressure on the presenting part to keep it off the cord The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean.
The pregnant client presents with regular contractions that she describes as "strong." Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information? 1. the client is experiencing early labor 2. the client is experiencing false labor 3. the client has experienced cervical ripening 4. the client has experienced lightening
1. the client is experiencing early labor Early labor is a pattern of labor that occurs when contractions become regular and the cervix dilates to 3 cm.
The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while laying on her back. Which intervention should the nurse implement immediately? 1. turn the client onto her left side 2. turn the client onto her right side 3. notify the attending obstetrician 4. apply oxygen by nasal cannula
1. turn the client onto her left side When the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the sub renal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression.
The nurse explained the process of cervical effacement to the client in early labor. Which statement indicates that she understands the information? 1. "the cervix will widen from less than 1 cm to about 10 cm" 2. "the cervix will pull or draw up and become paper-thin" 3. "the cervical changes will cause my membranes to rupture" 4. "the cervical changes will help my baby to change positions"
2. "the cervix will pull or draw up and become paper-thin" In cervical effacement, the cervix progressively changes from a thick and long structure to paper thin. This statement indicates that the client understands the information.
The nurse's laboring client is being electronically monitored during her labor. The baseline FHR throughout labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR? 1. tachycardia 2. bradycardia 3. late decelerations 4. within normal limits
2. bradycardia An FHR baseline less than 110 is classified as bradycardia.
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond? 1. conclude that there is a problem with the baby and call for help 2. check that there is adequate gel under the transducer and reposition 3. give the client oxygen via facemark at 8 to 10 liters per minute 4. auscultate FHR by fetoscope and assess maternal vital signs
2. check that there is adequate gel under the transducer and reposition When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem.
The pregnant client arrives at the triage unit. The nurse assesses that she is at 4/50/-1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding? 1. time and amount of last meal 2. number of weeks' gestation 3. who is attending the delivery 4. history of previous illnesses
2. number of weeks' gestation Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and ensure adequate fetal lung maturity. If she is full term, the labor process could continue.
The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60-70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document? 1. occiput anterior 2. occiput posterior 3. left occiput anterior 4. right occiput anterior
2. occiput posterior An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder.
The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/90 mm Hg and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication? 1. placenta previa 2. placental abruption 3. bloody show 4. succenturiate placenta
2. placental abruption The nurse should immediately implement interventions for placental abruption. This occurs when the placenta separates from the uterine wall before the birth of the fetus. It is commonly associated with preeclampsia.
At 1 minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next? 1. notify the HCP 2. recheck the Apgar at 5 minutes after birth 3. initiate resuscitation measures immediately 4. swaddle and hand to mother for breastfeeding
2. recheck the Apgar at 5 minutes after birth Rechecking the Apgar score 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment.
The primigravida client has been pushing for 2 hours when the infant's head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse's interpretation of this information? 1. there is cephalopelvic disproportion 2. the infant has a shoulder dystocia 3. the infant's position is occiput posterior 4. the infant's umbilical cord is prolapsed
2. the infant has a should dystocia The "turtle sign" occurs when the infant's head suddenly retracts back against the mothers perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant's anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant.
The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor? 1. The client with a previous cesarean birth 2. the primigravida client at 41 weeks 3. the client with preeclampsia 4. the client with gestational diabetes
2. the primigravida client at 41 weeks The client who is overdue by 7 days but has a reassuring FHR pattern is able to have intermittent fetal monitoring.
The nurse's laboring client presents with ruptured membranes, frequent contractions, and blood show. She reports a greenish discharge for 2 days. Place the nurse's actions in the order that they should be completed. 1. perform a sterile vaginal exam 2. assess the client thoroughly 3. obtains fetal heart tones 4. notify the HCP
3, 1, 2, 4 Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing non reassuring fetal status. Perform a sterile vaginal exam to determine the labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is the last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question? 1. prepare for possible cesarean section 2. place the client in a knee-chest position 3. initiate a low-dose oxytocin IV infusion 4. give terbutaline 0.25 mg subQ
3. initiate a low-dose oxytocin IV infusion The nurse should question the administration of oxytocin. Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression.
The nurse is caring for the 30-week-pregnant client who is having contractions every 1.5 to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. Delivery is imminent. What intervention is most important now? 1. administer a tocolytic agent 2. providing teaching on premature infant care 3. notify neonatology of the impending birth 4. prepare for a cesarean section birth
3. notify neonatology of the impending birth The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/-2, RSP. How should the oncoming shift nurse interpret this documentation? 1. the fetus is approximately 2 cm below maternal ischial spines. 2. the cervix it totally dilated and effaced, with fetal engagement. 3. the fetus is breech and posterior to the client's pelvis. 4. the fetal lie is transverse, and the fetal attitude is flexion
3. the fetus is breech and posterior to the client's pelvis The nurse should interpret 3/100/-2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother's pelvis (R), with the sacrum as the specific presenting part (S), which is a breach position. The fetus is also posterior.
The labor nurse observes a sinusoidal FHR pattern on the monitor. How should the nurse interpret this? 1. the fetus may be in a sleep state 2. congenital anomalies are possible 3. this may indicate severe fetal anemia 4. this predicts normal fetal well-being
3. this may indicate severe fetal anemia A sinusoidal pattern, which is regular, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions.
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus's long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse's documentation of the lie of the fetus? 1. vertex 2. breech 3. transverse 4. brow
3. transverse A transverse lie occurs in 1 in 300 births and is marked by the fetus's lying in a side-lying position across the abdomen.
The pregnant client has been pushing for 2.5 hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse's actions in caring for this client in the correct sequence. 1. apply suprapubic pressure per direction of the HCP 2. place the client in exaggerated lithotomy position 3. catheterize the client's bladder 4. call for the neonatal resuscitation team to be present 5. prepare for an emergency cesarean birth
4, 2, 1, 3, 5 Call for the neonatal resuscitation team to be present because of fetal distress. Place the client in exaggerated lithotomy position sot he McRobert's maneuver can be performed (flexing her thighs sharply on her abdomen may widen the pelvic outlet and let the anterior shoulder be delivered) Apply suprapubic pressure per direction of the HCP. This is completed in an effort to dislodge the shoulder from under the pubic bone Catheterize the client's bladder. This will empty the bladder to make more room for the fetal head. Prepare for an emergency cesarean birth. This will be performed if all efforts for a vaginal birth fail.
The laboring multigravida client's last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. which action should the nurse perform first? 1. encourage the client to push 2. notify the obstetrician or midwife 3. help the client to the bathroom 4. complete another vaginal exam
4. complete another vaginal exam The nurse should first evaluate labor progress by performing another vaginal exam. Previously, the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (1+). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part.
The nurse administers butorphanol tartrate to the client in active labor. What is the nurse's most important action to help prevent side effects from the medication? 1. assess the client's bladder for distention 2. place the client on seizure precautions 3. assess the client's body for itchy rash 4. evaluate the client's vital signs and pulse oximetry
4. evaluate the client's vital signs and pulse oximetry Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both mother and fetus can occur with butorphanol tartrate.
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal? 1. cloudy in color 2. has a strong odor 3. meconium stained 4. has a pH of 7.1
4. has a pH of 7.1 The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material.
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase? 1. transition 2. active 3. active pushing 4. latent
4. latent During the latent phase, the client is usually happy and talkative.
The nurse is unable to determine the fetal position for the laboring client who is morbidly obese. What should the nurse plan to do to obtain the most accurate method of determining fetal position in this client? 1. inspect the client's abdomen 2. palpate the client's abdomen 3. perform a vaginal examination 4. perform trans abdominal ultrasound
4. perform transabdominal ultrasound Real-time trans abdominal ultrasound is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client.
The client in labor received an epidural anesthesia 20 minutes ago. The nurse assesses that the client's BP is 98/62 mm Hg and that the client is lying supine. What should the nurse do next? 1. increase the lactated Ringer's infusion rate 2. elevate the client's legs for 2 to 3 minutes 3. place the bed in 10- to 20- degree Trendelenburg 4. position the client in a left side-lying position
4. position the client in a left side-lying position The first action is to place the client in a left side-lying position. This displaces the uterus and alleviates aortocaval compression.
The nurse admits the client at 34 weeks' gestation for preterm labor as a result of a battledore placenta. The nurse should plan to monitor for which most common complication associated with battledore placenta? 1. late abortion 2. fetal demise 3. postpartum hemorrhage 4. preterm labor with bleeding
4. preterm labor with bleeding A battledore placenta occurs when the umbilical cord is inserted at or near the placenta margin. It most commonly results in preterm labor and bleeding.
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first? 1. prepare for delivery 2. notify the obstetrician 3. apply oxygen nasally 4. reposition the client
4. reposition the client Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse's interventions in sequence that they should occur. 1. administer oxygen via facemask 2. have the HCP paged if the prolonged decelerations have not resolved 3. place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low 4. increase the rate of the IV fluids 5. assist the client into a different position 6. prepare for a vaginal examination and fetal scalp stimulation
5, 1, 4, 2, 6, 3 Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to receive the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapsed and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean if the HR remains low.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
8 The newborn would receive 1 point because the HR is below 100 bpm, 2 points for a good cry (respiratory effort), 2 points for being well flexed (muscle tone), 2 lints for good reflex irritability (reflex response), and 1 point for a pink boy with blue extremities (color).
The nurse is caring for two maternity clients who are in labor. The nurse determines that head entrapment is most likely to occur with which delivery presentation?
A breech delivery is most likely to be associated with head entrapment because the head is the largest part of the fetal body, and it is delivered last in a breech delivery.