Labor & Postpartum Study Guide
What does green amniotic fluid mean?
It is meconium-stained. The fetus has had an episode of loss of sphincter control, allowing meconium to pass into amniotic fluid. Pg 80
What are the three phases of stage 1 labor?
Latent phase Active phase Transition Maternal pg 70
List the signs of postpartum thrombophlebitis
Leg pain & tenderness Unilateral area of swelling, warmth, and redness Hardened vein over the thrombosis Calf tenderness PG 101
What should the lochia look like one day after giving birth?
Lochia rubia (this flow lasts 1-3 days after delivery) Pg 92
Macrosomia
Longer labor Possible c section
What does the nurse do to a boggy uterus?
Massage the fundus in a circular motion Pg 92
Med that assist w/ involution of the uterus
Methergine Pitocin Carboprost/hemabate Cytotec/misprostol
vaginal birth after cesarean (VBAC)
Most common risks are hemorrhage and uterine rupture No pitocin
HIV pt in labor
NO episiotomy NO forceps NO vacuum extraction NO internal fetal monitoring NO breastfeeding YES bloodless delivery by c section
List meds that stop preterm labor
Nifedipine Magnesium sulfate Indomethacin Pg 62
Is breastfeeding a good contraceptive method for a teenage mom?
No, pregnancy can occur while breastfeeding even though menses has not returned. Pg 93
Prolapsed umbilical cord
Occurs when the umbilical cords is displaced, preceding the presenting part of the fetus, or protruding through the cervix Pg 79
Uterine involution
Occurs with contractions of the uterine smother muscle, whereby the uterus returns to its prepregnant state Pg 92 Decreases by one finger breadth per day
Lochia serosa
Pinkish brown, watery discharge consisting of serum, WBCs, epithelial cells, and debris from the uterine lining. Lasts from approx day 4 to day 10 after delivery. Pg 92
The patient has late decelerations on the tocometer, what do you do?
Place pt in side-lying position Increase rate of IV maintenance solution Discontinue oxytocin if being infused Administer oxygen at 8-10 L/min via nonrebreather face mask Correct hypotension by elevating pt's legs Notify the HCP Assist w/ placement of an internal monitor Prepare for vaginal or cesarean birth if there is no change in pattern Pg 85
Inspect the perineum for episiotomy/lacerations w/ REEDA assessment
R - redness (erythema) E - edema E - ecchymosis D - drainage, discharge A - approximation
During labor, what position causes maternal hypotension and feta; hypoxia?
Supine
Postpartum assessment
TEMP ELEVATIONS should last for only 24 hrs, shouldnt be grater than 100.4 F Tachycardia & hypotension can occur due to decreased blood volume/hemorrhage
When do you take a BP on a pt in labor?
Take BP between contractions (after one ends, before next contraction begins)
How can you tell if the bladder is full postpartum?
The fundus is displaced laterally Pg 92
Homans' sign
Used to check for thrombophlebitis. W/ knees flexed, the nurse dorsiflexes the foot. Pain in the foot or leg is a positive Homans' sign. Measure circumference of both legs.
Lochia alba
Yellowish or white creamy discharge consisting of serum, WBCs, epithelial cells, and debris from the mucous membrane lining the uterus. Lasts from approx day 11 up to 8 wks after delivery. Pg 92
Is it normal to have edema, bruising, and tenderness at an episiotomy site?
Yes
uterine inversion
a potentially fetal complication of childbirth means the placenta fails to detach from the uterine wall, and pulls the uterus inside out as it exits
?If the nitrazine paper turns blue and the fluid dries into a fern like shape, the fluid is _____.
alkaline pg 69
Mastitis
an infection of the breast involving the interlobular connective tissue and is usually unilateral PG 107
For breast engorgement...
apply cold compresses between feedings
Precipitous delivery
birth that occurs rapidly w/o MD or midwife in attendance
More babies, more risk of...
boggy uterus (poor fundal tone), bleeding, heavy lochia
Always support the _____________ during any assessment of the fundus
bottom of the uterus
Treating mastitis
completely empty both breasts at each feeding or use a breast pump
Epidural analgesia can cause the BP to _____________. Treat w/ ___________.
drop call MD for order to give IVF bolus 0.9% NS
If bladder is full and uterine is displaced, you will see...
excessive lochia bladder tenderness bulging bladder above symphysis pubis put in a foley
Uterine force
forces acting to expel fetus
The uterus becomes displaced and deviated to the right when the bladder is ______.
full
Have ________ in room for neonatal resp depression after mother had Demerol 3 ins prior to precipitate delivery
narcan
When infant's head crowns, mother should...
pant
Lochia
post-birth uterine discharge that contains blood, mucus, and uterine tissue Pg 92
Uterine atony
results from the inability of the uterine muscle to contract adequately after birth and can lead to postpartum hemorrhage PG 104
Persistent lochia rubra in the early postpartum period beyond day 3 can indicated...
retained placental fragments PG 93
Effacement
thinning of the cervix
A distended bladder as a result of urinary retention can cause...
uterine atony and displacement Pg 96
Rupture of membraness
First monitor for fetal distress... FHR Find out what time the membranes ruptured Infection
What happens in stage 2 of labor?
Full dilation Progresses to intense contraction every 1-2 minutes Birth Pg 70
What will the HR & BP do if the postpartum pt is hemorrhaging?
HR will increase BP will decrease PG 103
Don't give methergine to...
HTN pt Pt in labor
Women is experiencing back labor
Have husband rub back and provide sacral counter pressure
What does sacral counter pressure help with?
Helps to alleviate back pain associated with fetal occiput position
?A primagravida has soaked 2 peripads with blood in 30 minutes. What is happening? What do you need to do?
Hemorrhage (pg 93) Massage = MD = meds
signs of preeclampsia
Hypertension Swelling of hands & face Proteinuria Blurred vision
Dinoprostone & Misprostol
INDICATION: inducing labor (ripening of cervix)
Relief of perineal discomfort
Ice packs for 24 hrs, then warm sitz bath
What does it mean if lochia is foul smelling?
Indicates infection PG 93
What do you do if the postpartum pt passes a quarter sized blood clot?
(indicates hemorrhage) *Firmly massage the uterine fundus. *Monitor VS. *Monitor for source of bleeding: - palpate fundus for height, firmness, and position. If uterus is boggy, massage fundus. - monitor lochia for color, quantity, and clots. *Palpate bladder for distention. *Insert and indwelling catheter to check kidney function and obtain an accurate measurement of urinary output. *Maintain IV fluids to replace fluid volume loss w/ IV isotonic solutions (lactated Ringer's, 0.9% sodium chloride). *Assist w/ administration of colloid volume expanders (such as albumin) and blood products. *Provide oxygen at 2-3 L/min per nasal cannula, and monitor O2 sat. *Elevated pt's legs to 20-30 degrees to increase venous return PG 103
How many cm must the pt be dilated for the MD to allow her to push?
10 cm
Do NOT give Demerol to a pt in stage _____ labor.
2
First stage of labor: active phase
2-3 hr Cervical dilation: 4-7 cm Contractions: More regular, moderate to strong Frequency - 3 to 5 min Duration- 40 to 70 sec Maternal characteristics: Rapid dilation & effacement Some fetal descent Feelings of helplessness Anxiety & restlessness increases as contractions become stronger Pg 70
First stage of labor: transition
20-40 min Cervical dilation: 8-10 cm Contractions: Strong to very strong Frequency - 2 to 3 min Duration - 45 to 90 sec Complete dilation Maternal characteristics: Tired, restlessness, & irritable Feeling out of control, pt often states "cannot continue" Can have nausea & vomiting Urge to push Increased rectal pressure and feelings of needing to have a BM Increased bloody show
First stage of labor: latent phase
4-6 hr Cervical dilation: 0-3 cm Onset of labor Contractions: Irregular, mild to moderate Frequency - 5 to 30 min Duration - 30 to 45 sec Some dilation & effacement Mom may be talkative & eager Pg 70
A nurse is caring for a pt who is in labor and is experiencing late decelerations in the FHR. Which of the following actions should the nurse take first? A. assist the pt into the left lateral position B. apply oxygen at 10 L/min via a nonrebreather face mask C. increase the rate of the maintenance IV fluid D. prepare the pt for a vaginal exam
A (The nurse would do all these actions, but should do A first) pg 87 #4
After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? A. Shortens the second stage of labor B. Enlarges the pelvic inlet C. Prevents perineal edema D. Ensures quick placenta delivery
A NurseLabs
Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia
A NurseLabs
Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? A. Applying ice B. Applying a breast binder C. Teaching how to express her breasts in a warm shower D. Administering bromocriptine (Parlodel)
C NurseLabs, postpartum
The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? A. Risk for deficient fluid volume related to hemorrhage B. Risk for infection related to the type of delivery C. Pain related to the type of incision D. Urinary retention related to periurethral edema
A NurseLabs
Which of the following best describes preterm labor? A. Labor that begins after 20 weeks gestation and before 37 weeks gestation B. Labor that begins after 15 weeks gestation and before 37 weeks gestation C. Labor that begins after 24 weeks gestation and before 28 weeks gestation D. Labor that begins after 28 weeks gestation and before 40 weeks gestation
A NurseLabs
The antagonist for magnesium sulfate should be readily available to any client receiving IV magnesium. Which of the following drugs is the antidote for magnesium toxicity? A. Calcium gluconate B. Hydralazine (Apresoline) C. Narcan D. RhoGAM
A NurseLabs, antepartum
Which of the following observations indicates fetal distress? A. Fetal scalp pH of 7.14 B. Fetal heart rate of 144 beats/minute C. Acceleration of fetal heart rate with contractions D. Presence of long term variability
A NurseLabs, intrapartum
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? A. Massage the fundus until it is firm B. Elevate the mothers legs C. Push on the uterus to assist in expressing clots D. Encourage the mother to void
A NurseLabs, postpartum
On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? A. Ask the client to empty her bladder B. Straight catheterize the client immediately C. Call the client's health provider for direction D. Straight catheterize the client for half of her uterine volume
A NurseLabs, postpartum
A nurse is inspecting the perineal pad of a pt who is 24 hr postpartum. The pad is saturated w/ approx 12 cm of dark red discharge. Which of the following blood loss estimations should the nurse report to the charge nurse and document in the pt's medical record? A. moderate B. heavy C. light D. scant
A PG 99 #1
A nurse is reinforcing teaching w/ a pt who is 1 week postpartum and breastfeeding. The pt reports breast engorgement. Which of the following instructions should the nurse give to the pt? A. "apply cold compresses between feedings." B. "take a warm shower right after feedings." C. "apply breast milk to the nipples and allow them to air dry." D. "use the various infant positions for feedings."
A PG 99 #3
A primigravid pt in early labor is admitted and reports intense back pain w contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be MOST helpful for alleviating the pt's back pain during early labor? A. Applying counter pressure to the pt's sacrum during contractions B. Encouraging for the pt to remain in bed during early labor C. Positioning the pt on the left side with pillows for support D. Requesting that the nurse anesthetist administer epidural anesthesia
A Uworld, labor & delivery
A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement? A. allow newborn to nurse for at least 10-15 min on each breast B. apply ice packs to breasts for 15-20 min before breastfeeding C. decrease the frequency of breastfeeding D. manually express or pump breast milk several times each day
A Uworld, postpartum
A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse? A. calf warmth & redness B. elevated temperature C. elevated WBC count D. incisional discomfort
A Uworld, postpartum
A nurse in the labor & delivery unit is assisting w/ the care of a pt in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 min and 30-40 sec in duration. The RN performs a vaginal exam and finds the cervix is 2 cm dilated and 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is this pt experiencing? A. first stage, latent phase B. first stage, active phase C. first stage, transition phase D. second stage of labor
A pg 81 #1
A nurse is assisting w/ the care of a pt who is at 40 wks of gestation and experiencing contractions every 3-5 min and becoming stronger. A vaginal exam reveals that the pt's cervix is 3 cm dilated, 80% effaced, and -1 station. The pt asks for pain medication. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) A. encourage use of patterned breathing techniques B. insert an indwelling urinary catheter C. administer opioid analgesic med D. suggest application of cold E. provide ice chips
A, C, D pg 81 #3
Nonpharmacological Pain Management
Aroma therapy Breathing techniques Imagery Music Use of focal points Subdued lighting Therapeutic touch (back rubs, massage) Walking, rocking Effleurage Sacral counterpressure Application of heat or cold TENS therapy Hyrotherapy (whirlpool or shower) Acupressure Frequent maternal position changes (semi-sitting, squatting, kneeling, rocking back & forth, supine only w/ the placement of a wedge under one of the pt's hips) Pg 74
A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."
B NurseLabs
While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? A. Calcium gluconate B. Protamine sulfate C. Methylergonovine (Methergine) D. Nitrofurantoin (macrodantin)
B NurseLabs
What happens in stage 4 of labor?
Delivery of placenta Maternal stabilization of vital signs Pg 70
Fetal distress is present when
FHR is below 110/min or above 160/min FHR shows decreased or no variability There is fetal hyperactivity or no fetal activity PG 80
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A. A form of biofeedback to enhance bearing down efforts during delivery B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus C. The application of pressure to the sacrum to relieve a backache D. Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest
B NurseLabs, intrapartum
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? A. Hypotonic contractions B. Forceps delivery C. Schultz delivery D. Weak bearing down efforts
B NurseLabs, intrapartum
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. Stop the oxytocin infusion B. Change the client's position C. Prepare for immediate delivery D. Take the client's blood pressure
B NurseLabs, intrapartum
A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? A. Paleness of the calf area B. Enlarged, hardened veins C. Coolness of the calf area D. Palpable dorsalis pedis pulses
B NurseLabs, postpartum
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A. A temperature of 100.4*F B. An increase in the pulse from 88 to 102 BPM C. An increase in the respiratory rate from 18 to 22 breaths per minute D. A blood pressure change from 130/88 to 124/80 mm Hg
B NurseLabs, postpartum
Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: A. Amount of lochia B. Blood pressure C. Deep tendon reflexes D. Uterine tone
B NurseLabs, postpartum
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation
B NurseLabs, postpartum
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids
B NurseLabs, postpartum
A nurse is caring for a pt who has postpartum psychosis. Which of the following actions is the nurse's priority? A. reinforce the need to take antipsychotics as prescribed B. ask the pt if she has thoughts of harming herself or her infant C. monitor the infant for indications of failure to thrive D. review the pt's medical record for a history of bipolar disorder
B PG 111 #5
The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? A. discomfort during fundal palpation B. foul-smelling lochia C. oral temp 100.1 F D. WBC count 24,000/mm3
B Uworld, Postpartum
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? A. lochia that soaks a perineal pad every 2 hrs B. persistent headache with blurred vision C. red, painful nipple on one breast D. strong-smelling vaginal discharge
B Uworld, postpartum
A pt experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first? A. check the amniotic fluid for meconium B. monitor FHR for distress C. dry the pt and make her comfortable D. monitor uterine contractions
B pg 81 #2
A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? SELECT ALL THAT APPLY A. cease breastfeeding from right breast B. increase oral fluid intake C. reduce frequency of feeds to every 8 hrs in right breast D. take ibuprofen as needed for pain E. use underwire bra 24 hrs a day for support
B, E Uworld, Postpartum
What do you do if the pt says "I feel like I need to push"?
Believe her and look No pushing till 10 cm Pant
Which term signifies labor is about to begin?
Bloody show
The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following? A. Lanugo B. Hydramnio C. Meconium D. Vernix
C NurseLabs
A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? A. Preparatory phase B. Latent phase C. Active phase D. Transition phase
C NurseLabs, intrapartum
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of pitocin IV infusion
C NurseLabs, intrapartum
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A. Ask the client to turn on her side B. Ask the client to lie flat on her back with the knees and legs flat and straight C. Ask the mother to urinate and empty her bladder D. Massage the fundus gently before determining the level of the fundus.
C NurseLabs, postpartum
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? A. Hypertension B. Cervical and vaginal tears C. Urine retention D. Endometritis
C NurseLabs, postpartum
A nurse is reinforcing teaching w/ a pt who is breastfeeding and has mastitis. Which of the following statements should the nurse make? A. "limit the amount of time the infant nurses on each breast." B. "nurse the infant only on the unaffected breast until resolved." C. "completely empty each breast at each feeding or use a pump." D. "wear a tight fitting bra until lactation has ceased."
C PG 111 #2
A nurse is reinforcing discharge instructions w/ a pt who is 4 weeks postpartum. The nurse should instruct the pt to contact her provider for which of the following findings? A. scant, nonodorous white vaginal discharge B. uterine cramping during breastfeeding C. sore nipple w/ cracks and fissures D. decreased response w/ sexual activity
C PG 99 #4
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first? A. administer 10 units oxytocin IM B. apply oxygen via nonrebreather mask at 10 L/min C. assist the pt to void on a bedpan D. draw blood for a hemoglobin and hematocrit level
C Uworld, postpartum
Heparin for DVT
CLASSIFICATION: anticoagulant THERAPEUTIC INTENT: given IV to prevent formation of other clots and to prevent enlargement of the existing clot NURSING ACTIONS: -Initially, heparin is administered by an RN via a continuous IV infusion for 3-5 days w/ doses adjusted according to coagulation studies. -Protamine sulfate, the heparin antidote, should be readily available. -Monitor aPTT (1.5-2.5 times the control level of 3-40 seconds) CLIENT EDUCATION: report bleeding from the gums or nose, increased vaginal bleeding, blood in the urine, and frequent bruising. PG 102
Terbutaline
CLASSIFICATION: tocolytic THERAPEUTIC INTENT: relax the uterus priot yo D&C if placental expulsion with oxytocics is unsuccessful PG 106
Cytotec (misoprostol)
CLASSIFICATION: uterine stimulant THERAPEUTIC INTENT: control postpartum hemorrhage NURSING ACTIONS: monitor uterine tone and vaginal bleeding PG 103
Oxytocin (Pitocin)
CLASSISIFICATION: uterine stimulant THERAPEUTIC INTENT: promote uterine contractions NURSING ACTIONS: -Monitor uterine tone and vaginal bleeding -Monitor for adverse reaction of water intoxication (lightheadedness, nausea, vomiting, headache, malaise) PG 103
What is the most reliable indicator the pt is in true labor?
Cervical dilation & effacement pg 72
Postpartum hemorrhage
Considered to occur is the pt loses more than 500 mL of blood after a vaginal birth or more than 1000 mL of blood after a cesarean birth PG 103
Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? A. Occurring at irregular intervals B. Starting mainly in the abdomen C. Gradually increasing intervals D. Increasing intensity with walking
D NurseLabs
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A. Presence of deep tendon reflexes B. Serum magnesium level of 6 mEq/L C. Proteinuria of +3 D. Respirations of 10 per minute
D NurseLabs, antepartum
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension
D NurseLabs, intrapartum
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? A. Postural hypotension B. Temperature of 100.4°F C. Bradycardia — pulse rate of 55 BPM D. Pain in left calf with dorsiflexion of left foot
D NurseLabs, postpartum
The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician? A. A dark red discharge on a 2-day postpartum client B. A pink to brownish discharge on a client who is 5 days postpartum C. Almost colorless to creamy discharge on a client 2 weeks after delivery D. A bright red discharge 5 days after delivery
D Nurselabs
A nurse is assisting w/ the care of a pt in active labor. When last examined 2 hr ago, the pt's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The pt suddenly states her water broke. The monitor reveals a FHR of 80-85/min. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the pt's vagina. Which of the following actions should the nurse perform first? A. place the pt in the Trendelenburg position B. apply finger pressure to the presenting part C. administer oxygen at 10 L/min via a face mask D. call for assistance
D PG 81 #5
A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first? A. check for pooled blood under buttocks B. increase IV oxytocin infusion rate C. monitor BP & pulse D. perform firm fundal massage
D Uworld, labor & delivery
A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? A. cervical lacerations B. inversion of the uterus C. uterine atony D. vaginal hematoma
D Uworld, labor & delivery
A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely
D NurseLabs, intrapartum
Lochia rubra
Dark red to brown "period-like" discharge, containing debris from sloughing of the uterus lining. Pg 92
What happens in stage 3 of labor?
Delivery of neonate Delivery of placenta Placental separation & expulsion Pg 70
