Maternity: Chapter 14
The nurse has just administered butorphanol (Stadol) 2 mg IV to a laboring patient. Which change in the fetal heart rate pattern would the nurse consider to be a result of this medication? a) Decreased variability b) Increased variability c) Early decelerations d) Late decelerations
a) Decreased variability Rationale: Decreased variability is a common side effect when opioid analgesics are used.
The following are nursing measures commonly offered to women in labor. Which nursing intervention probably would be most effective in applying the gate-control theory for relief of labor pain? a) Massage the woman's back b) Encourage the woman to rest between contractions c) Give the prescribed medication d) Change the woman's position
a) Massage the woman's back Rationale: Gate control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area.
Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. Your first action would be to a) turn her on her left side or raise her legs. b) administer oxygen by facemask. c) ask her to inhale deeply at least five times. d) raise her head off the bed.
a) turn her on her left side or raise her legs. Rationale: Turning her to her side or elevating her legs increases blood volume in her central body, thereby increasing blood pressure.
The expected fetal heart rate response in an active fetus is which of the following: a) Increase in variability by 15 bpm b) Acceleration of at least 15 bpm for 15 seconds c) Decrease in variability for 15 seconds d) Deceleration followed by acceleration of 15 bpm
b) Acceleration of at least 15 bpm for 15 seconds Rationale: A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.
All of the following pain management modalities can slow labor if given too early EXCEPT a) Hydrotherapy b) Acupuncture c) Epidural anesthesia d) Narcotics
b) Acupuncture Rationale: Acupuncture can be used to augment labor. Epidural anesthesia and narcotics such as Demerol and butorphanol can slow labor progress if given too early.
A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural? a) Review the woman's medical history and laboratory results and interview her to confirm all information is accurate and up to date. b) Administer a fluid bolus through the IV line to reduce the risk of hypotension. c) Prepare a sterile field with the supplies and medications that will be needed. d) Place the woman in the fetal position on the table and keep her steady so that she won't move during the procedure.
b) Administer a fluid bolus through the IV line to reduce the risk of hypotension. Rationale: Epidurals can cause vasodilatation and result in hypotensive episodes. IV fluid bolus prior to epidural placement can help prevent the hypotensive episode.
A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which of the following substances is the nurse referring? a) Progesterone b) Endorphins c) Relaxin d) Prostaglandins
b) Endorphins Rationale: The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.
A pregnant client in her 32nd week of gestation has been admitted to a health care center with complaints of decreased fetal movement. Which of the following should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds? a) Fetal head b) Fetal buttocks c) Fetal shoulders d) Fetal back
b) Fetal buttocks Rationale: The nurse assessing the client should first determine the fetal back before placing the fetoscope on the client's abdomen. The fetal back is determined first because it is through the back that the heart signals are best transmitted. During labor, the fetal heart rate should be assessed to check for any variations indicating distress. Fetal heart rate is auscultated by placing a fetoscope on the client's abdomen in the area of the fetal back. Determining the fetal head, shoulders, and the buttocks would be of no help in localizing the heart sounds.
At which time during a woman's labor might the nurse assist with a pudendal block? a) Early stage labor b) Just before delivery c) Before dilation only d) Just after delivery
b) Just before delivery Rationale: Pudendal block is a local block in the perineal area and is used to numb for delivery. Application before labor begins or while it is in the early stages would be counterproductive, as the patient would not have proper feeling and would have a harder time pushing. After delivery it is pointless; the most painful part is over.
You place an external fetal monitor on a woman in labor. Which of the following instructions would be best to give her? a) Avoid using her call bell to reduce interference. b) Lie on her side so she is comfortable. c) Avoid flexing her knees so her abdomen is not tense. d) Lie supine so the tracing does not show a shadow.
b) Lie on her side so she is comfortable. Rationale: The best position for all women during labor is on their side.
A woman's perception of pain can differ according to all of the following EXCEPT a) Fear, anxiety, and self-efficacy b) The presentation, lie, and attitude of the fetus c) Psychosocial, physiologic, and cultural influences d) Her expectations and preparation for labor e) The length of her labor
b) The presentation, lie, and attitude of the fetus Rationale: Fetal position can influence a patient's perception of pain. Fetal attitude does not influence a patient's perception of pain.
While caring for woman in labor the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is: a) Cord compression b) Uteroplacental insufficiency c) Maternal hypotension d) Maternal fatigue
b) Uteroplacental insufficiency Rationale: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
When a patient is counseled about the advantages of epidural anesthesia, which statement made by the counselor would be incorrect? a) "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." b) "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." c) "You have no trouble walking around and using the bathroom after you receive the epidural." d) "If you end up having a cesarean, the epidural can be used for anesthesia during surgery."
c) "You have no trouble walking around and using the bathroom after you receive the epidural." Rationale: Epidural anesthesia impairs mobility; most patients are placed on bed rest after epidural anesthesia is given. Urinary catheterization is frequently required.
The nurse instructs the client about skin massage and the gate control theory of pain. Which of the following statements would be appropriate for the nurse to include for patient understanding of the nonpharmacological pain relief methods? a) The gating mechanism is located at the pain site b) Pain perception is decreased if anxiety is present c) A technique to prevent the painful stimuli from entering the brain d) The gating mechanism opens so all the stimuli pass through to the brain
c) A technique to prevent the painful stimuli from entering the brain Rationale: Gate-control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. Gate control does not need to be applied directly to the site of the pain. Anxiety heightens the painful feelings. Gating blocks the flow of painful stimuli to the sensory centers in the brain.
The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded and distended, non-tender. What intervention should the nurse take next? a) Ask the patient if the mass has always been present b) Notify a physician about the mass c) Check the chart for the last void d) Assume this is part of the uterus
c) Check the chart for the last void Rationale: The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the patient and offer to assist the patient to void or prepare to catheterize the patient to empty the bladder. This can be taken care of by the nurse. The patient would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.
Mrs. Timms is now in the second stage of labor. While doing your assessment, what data would you gather at this time? a) Vital signs every hour b) Absence of deep tendon reflexes c) Contraction pattern every 15 minutes d) Late decelerations on the EFM tracing
c) Contraction pattern every 15 minutes Rationale: Assess the contraction pattern every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity).
Early in labor, a pregnant client asks why contractions hurt so much. Which of the following should the nurse mention? a) Release of endorphins in response to contractions b) Distraction of the brain cortex by other stimuli c) Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels d) Blocking of nerve transmission via mechanical irritation of nerve fibers
c) Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Rationale: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which of the following? a) Increased cervical dilation b) Decreased sedation c) Less anxiety d) Increased feelings of control
c) Less anxiety Rationale: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.
When completing a routine admission on the labor and delivery unit for induction of labor, after the admission information is collected, what is the next priority in planning care for the patient? a) Head to toe physical b) Placement of IV c) Vital signs d) Fetal assessment
d) Fetal assessment Rationale: After the initial information is gathered, it is prudent to complete an assessment on the fetus. The woman is placed on a fetal monitor to check fetal heart rate and the other activities can be completed while the mother remains on the fetal monitor. Once the fetus has been assessed, the mother is then assessed and prepared for the labor process.