Intrapartum PrepU 240
The nurse is caring for a client in the first stage of labor who states, "I am scared. The last time I gave birth, I was in labor for 32 hours, it was awful." What is the nurse's best response?
"Let's talk about options that can keep you more comfortable this time." A client's ability to cope during labor and childbirth may be hampered by fear of a long, painful or difficult childbirth. A previous negative experience may increase these fears. The client's anxiety stems from her past history of a long labor. Engaging the client in planning options will give more control and let her know that the nurse will support her through this labor. An immediate epidural may lengthen labor time, the nurse cannot know that labor will be shorter. Oxytocin is not an appropriate option at this time.
Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently?
Alterations in cardiovascular function affect the fetus. During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease.
The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?
Check the fetal heart rate for bradycardia. After a client has an amniotomy, the nurse should ensure that the cord is not prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes does not indicate an imminent birth.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly. Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions.
During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. What is the nurse's priority intervention?
Massage the client's fundus. A boggy (soft and poorly contracted) fundus signals uterine atony. To correct this condition, the nurse should massage the fundus until it becomes firm and clots are expressed. Allowing a boggy fundus to persist would place the client at high risk for postpartum hemorrhage. The fundal massage should begin immediately, after which the nurse can check the pad. The nurse should notify the healthcare provider only if the client's fundus doesn't respond to massage. Although an empty bladder can facilitate uterine contraction, the priority is not the insertion of a catheter.
The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention?
Prepare for birth of the neonate. A client who is fully dilated is about to begin pushing. Appropriate actions for this time include assessing vital signs every 15 minutes, positioning for effective pushing, and preparing for delivery. Oxytocin is administered to induce labor or to help the uterus contract after birth; it would be inappropriate to administer to a client entering the second stage of labor. It is inappropriate to insert an epidural when the client is ready to start pushing. Status of membranes would have been determined during the sterile vaginal exam.
Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
an increased sense of rectal pressure An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.
The end of the third stage of labor is marked by what event?
delivery of the placenta The third stage of labor is marked by the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 2 hours after birth.
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?
duration, frequency, and intensity The nurse should document the duration, frequency, and intensity of uterine contractions. Dilation refers to the number of centimeters the cervix is dilated; it doesn't describe uterine contractions. Maternal position doesn't help describe uterine contractions. Dilation and effacement both refer to the condition of the cervix, not uterine contractions.
A nurse is caring for a client in labor. Which assessment finding indicates fetal distress?
fetal blood pH less than 7.2 A fetal blood pH less than 7.2 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.2 to 7.3 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. Lack of meconium staining, early decelerations in fetal heart rate during contractions, and an increase in fetal heart rate with fetal scalp stimulation are all normal findings.
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?
fetal heart rate of 80 beats/minute
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply.
interpretation of the fetal monitor strip analgesia or anesthesia being used prior birth history amount of vaginal bleeding or discharge support persons with the client
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them?
the client's partner A legal document stating that the client's partner is the healthcare surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client isn't able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make healthcare decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents don't have rights to make healthcare decisions for pregnant adolescents. The court system wouldn't make the decision if the client has designated a legal healthcare surrogate.
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?
umbilical cord prolapse Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.
A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?
Prepare the client and partner for a cesarean birth as soon as possible. For a client with active genital herpes lesions, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Penicillin G is given for a bacterial colonization of group B streptococcus. Tocolytics are given to stop labor; they are not appropriate treatment. Valacyclovir is a treatment for an active herpes infection, but would not work in time for the client to deliver vaginally.
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?
What is your expected due date?" When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.
The nurse is caring for a client who is attempting a trial of labor (attempt a vaginal birth after cesarean). Contractions are 1.5 minutes apart with a duration 75 to 90 seconds. The client reports a "sharp, tearing" pain, and the electronic fetal monitor (EFM) is no longer recording contractions. What is the priority nursing action?
Prepare the client for an emergency cesarean birth. The priority action is to prepare for an emergency cesarean birth as a sharp, tearing pain along with absence of contractions on the EFM indicate a uterine rupture, which is an extreme emergency. Performing an SVE, inserting an intrauterine pressure catheter, and repositioning the client do not address the emergency situation and are not the priority action.