Maternal/newborn Intrapartum
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean birth may be necessary?
Fetal heart rate of 80 beats/minute Explanation: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean birth to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.
A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?
Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Explanation: The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?
Influence of the extended family Explanation: The influence of the extended family is the cultural factor that is causing the nurse's dilemma. It is common for English-speaking women to defer to an extended family member in both formal and informal decision-making situations. Language barriers may present challenges at times, but translators may be involved in particular when discussing health-related decisions to ensure understanding.
A client who has abruptio placentae exhibits cyanosis in her earlobes, capillary filling time >3 seconds, and reports "heartburn." Which of the following is the best nursing intervention?
Notify the healthcare provider immediately. Explanation: The manifestations of earlobe cyanosis, capillary filling time >3 seconds, and gastric distress in this client may indicate disseminated intravascular coagulation. The healthcare provider should be notified immediately . Increasing the ambient temperature may increase client comfort, and an assessment of vaginal bleeding is indicated. Sitting the client up in bed is not indicated.
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?
blue Explanation: If the client's membranes have ruptured, the nitrazine paper will turn blue, an alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other fluid forms this type of pattern.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
client at 38 weeks' gestation with active herpes lesions Explanation: Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months' gestation, the breech position is not a concern.
13s The health care provider (HCP) orders an amniocentesis for a primigravid client at 37 weeks' gestation to determine fetal lung maturity. Which is an indicator of fetal lung maturity?
lecithin-sphingomyelin (L/S ratio) Explanation: To determine fetal lung maturity, the sample of amniotic fluid will be tested for the L/S ratio. When fetal lungs are mature, the ratio should be 2:1. Bilirubin indicates hemolysis and, if present in the fluid, suggests Rh disease. Red blood cells should not appear in the amniotic fluid because their presence suggests fetal bleeding. Barr body determination is a chromosome analysis of the sex chromosomes that is sometimes used when a child is born with ambiguous genitalia.
The nurse is caring for a client in labor. The client states she feels like she "has to push." The vaginal exam reveals that the client is 8 cm dilated. Which of the following responses made by the nurse is correct?
"I know you want to push, but your cervix is not dilated enough. Keep breathing through your contractions." Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema, tissue damage, and may impede fetal descent. There is no need to call the healthcare provider, as this feeling is natural at this stage of labor. Giving the client IV pain medication at 8 cm can cause fetal respiratory distress.
A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?
Assess the fetal heart rate. Explanation: Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium-stained fluid. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelerations), the health care provider (HCP) should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The HCP may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.
A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?
Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.
The client and her husband are very distressed and state that they feel their nurse has been negligent in providing care during their labor. Which of the following is the nurse's best defense against an accusation of negligence?
The national standards of practice were met when providing care. Explanation: Following recognized standards of practice will help protect the nurse from an accusation of negligence. Nurses are responsible and accountable for their own nursing actions. Acting on the advice of a novice or experienced colleague is irresponsible and not a feasible defense for an accusation of negligence. It is expected that the nurse will have the required certifications for practice on the nursing unit. As per the scope of nursing practice, nurses are expected to follow the physician's written orders. This does not exempt or protect the nurse from accusations of negligence.
The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict?
"I will make every effort to work with your cultural beliefs." Explanation: The nurse knows he/she must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by health care providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.
Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate?
Give the client a paper bag and have her breathe into it. Explanation: Hyperventilation results in excess carbon dioxide being eliminated from the body. Rebreathing into a paper bag or cupping the hands is beneficial because it increases the carbon dioxide remaining in the lungs during breathing. Although taking whiffs of oxygen via nasal cannula may increase oxygen intake with breathing, it will not replace the lost carbon dioxide, the major problem with hyperventilation. Having the client hold her breath has no effect on minimizing the excess carbon dioxide being eliminated. However, doing so can lead to increased intracranial pressure. Breathing with forceful inspirations will not resolve the hyperventilation nor will it replace the carbon dioxide deficiency.
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?
Instruct the partner on touch, massage, and breathing patterns. Explanation: If the unprepared client has a support person, the nurse should focus on that person's supporting role, demonstrating touch, massage, and simple breathing patterns. Teaching about muscle relaxation, hypnosis, or pain transmission is inappropriate at this time because this information may make the client and her partner more anxious.
The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. Which of the following interventions should the nurse include in the client's plan of care?
Repositioning the client on her side Explanation: Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus. Discontinuing the fetal monitor would be inappropriate for a client in labor who is having variable decelerations. Calling the healthcare provider without repositioning the client first would be inappropriate. Terbutaline may discontinue the uterine contractions but may not stop the variable decelerations.
The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:
bladder status. Explanation: The bladder status should be monitored throughout the labor process, but especially before the client begins pushing. A full bladder can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that the client is receiving intravenous fluids, contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and fetal heart rate variability throughout labor, this does not affect the client's ability to push. There is no need to recheck cervical dilation because increasing the frequency of examinations can increase the client's risk for infection.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor?
effects of analgesic medication Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhythmias. Maternal fatigue, fetal malposition, and small-for-gestational-age fetus are not commonly associated with decreased variability.
19s After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?
hold her breath throughout the length of the contraction The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing. Semi-Fowler's position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired. The client should flex her thighs onto her abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter. The client should exert downward pressure as if she were having a bowel movement while pushing.
A primigravid client in active labor whose cervix is dilated to 5 cm and completely effaced is using the Lamaze method of prepared childbirth during labor. The client has been using slow-paced breathing and tells the nurse that this does not appear to be helping her during a contraction. The nurse should suggest to the client that she use which technique?
modified-pace breathing With time, habituation may occur, making slow-paced breathing less effective. The nurse should suggest to the client that she switch to modified-pace breathing, which is performed as an upper chest breath either through nose or mouth. A commonly taught method is three breaths, then a soft blow. Deep abdominal breathing is primarily useful in early labor. Pant-and-blow breathing typically is useful during the transition stage. Open-glottis breathing is useful for the second stage of labor and the birth process.
