Nursing 2nd Semester
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? 1 Changing the client's position 2 Taking the client's blood pressure 3 Stopping the client's oxytocin infusion 4 Preparing the client for an immediate birth
1 Changing the client's position Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.
The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In which stage of labor is this client? 1 First 2 Latent 3 Second 4 Transitional
1 First The client is in the first stage of labor because she is fully effaced but not yet completely dilated. The first stage lasts from the onset of contractions until full cervical effacement and dilation. The second stage of labor lasts from complete dilation to birth. Latent and transition are phases and not stages of labor. Latent is the first phase of the first and second stages of labor. Transition is the last of three phases occurring in the first stage of labor.
Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? 1 Reposition the client from supine to left lateral. 2 Increase the intravenous flow rate from 125 to 150 mL/hr. 3 Administer oxygen at a rate of 8 to 10 L/min by way of face mask. 4 Assess the maternal blood pressure for a systolic pressure below 100 mm Hg.
1 Reposition the client from supine to left lateral Hypotension is a common side effect of epidural anesthesia that results in decreased placental perfusion and late decelerations on the fetal monitor. The priority intervention is repositioning the client to relieve compression of the vena cava and increase venous return, which in turn increases placental perfusion. Administering oxygen and increasing the flow rate are correct interventions, but neither is the priority because these interventions would not be effective until compression of the vena cava has been relieved and placental perfusion increased. Assessing the maternal blood pressure for a systolic pressure below 100 mm Hg only provides data and does not correct the late deceleration.
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the client at this time? 1 The cervix dilates and becomes effaced in true labor. 2 Bloody show is the first sign of true labor. 3 The membranes rupture at the beginning of true labor. 4 Fetal movements lessen and become weaker in true labor.
1 The cervix dilates and becomes effaced in true labor The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question? 1 Usually fluctuate in length 2 Continuous, without relaxation 3 Related to time of membrane rupture 4 Accompanied by progressive cervical dilation
4 Accompanied by progressive cervical dilation Progressive cervical dilation is the only positive sign of true labor; the cervix dilates in response to regular, coordinated uterine contractions. The contractions of true labor increase in length and intensity. A continuous contraction may have an adverse effect on the fetus; immediate intervention is required. The membranes may rupture before contractions begin; more frequently they rupture after true labor is established.
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action? 1 Notifying the healthcare provider of possible head compression 2 Placing the client in a knee-chest position to avoid cord compression 3 Putting the client in a dorsal recumbent position to prevent compression of the vena cava 4 Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends
4 Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends The reading noted by the nurse represents early decelerations that occur with head compression during a contraction, with the fetal heart rate (FHR) returning to baseline at the end of the contraction. Head compression and cord compression are both common occurrences during a contraction; intervention is unnecessary if the FHR returns to baseline at the end of the contraction. The dorsal recumbent position will increase pressure on the vena cava and is contraindicated.
Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? 1 Facial redness and an urge to push 2 Bulging perineum, crowning, and caput 3 Less intense, less frequent contractions 4 Increased bloody show, irritability, and shaking
4 Increased bloody show, irritability, and shaking Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.
A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression? 1 Smooth, flat baseline tracings of 135 beats/min 2 Abrupt decreases in fetal heart rate that are unrelated to the contractions 3 Accelerations in the fetal heart rate of 10 beats/min above baseline 4 Decelerations when a contraction begins that return to baseline when the contraction ends
Abrupt decreases in fetal heart rate that are unrelated to the contractions Abrupt decreases in fetal heart rate that are unrelated to the contractions are variable decelerations that indicate cord compression. These are most common during the second stage of labor and are considered benign unless the heart rate does not recover adequately. A flat baseline reading indicates decreased variability and may have many causes, but it is not related to cord compression. Fetal heart rate accelerations are not related to cord compression. Decelerations when a contraction begins that return to baseline when the contraction ends indicate head compression during contractions; they are an expected, benign finding.
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? 1 Turn her onto her left side 2 Elevate the head of the bed 3 Place her feet on several pillows 4 Give her oxygen via a face mask
Correct1 Turn her onto her left side The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. Raising the head of the bed will not relieve uterine compression of the large vessels. Elevating the feet will not relieve uterine compression of the large vessels. Oxygen administration will not relieve uterine compression of the large vessels.
A pregnant client at 37 weeks' gestation is taught the signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report what? 1 Lower back pain 2 White vaginal discharge 3 Irregular strong contractions 4 Leakage of fluid from the vagina
Correct4 Leakage of fluid from the vagina Leakage may indicate rupture of the amniotic membranes; the client is at risk for an ascending infection from the vagina if birth does not occur within 24 hours or if early treatment is not instituted. Lower back pain is a common discomfort of pregnancy because the enlarged uterus causes a shift in the client's center of gravity. Leukorrhea is common during pregnancy because of increased vascularity of the cervix and increased production of mucus. Preparatory (Braxton Hicks) contractions occur at irregular intervals throughout pregnancy; they become stronger after the 28th week of gestation.
After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. During the assessment the nurse notes that the fetus's head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder? 1 Gently guiding the head downward 2 Gradually flexing the head toward the mother's thigh 3 Gently putting pressure on the head by pulling upward 4 Gradually extending the head above the mother's symphysis pubis
Gently guiding the head downward After the newborn's head has rotated externally, the nurse gently guides the head downward for the birth of the anterior shoulder. Gradually flexing the head toward the mother's thigh, gently putting pressure on the head by pulling upward, and gradually extending the head above the mother's symphysis pubis are all contraindicated.
Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration. 1 Elevating the legs 2 Repositioning the client from side to side 3 Increasing the rate of intravenous infusion 4 Administering oxygen by way of face mask
Repositioning the client from side to side A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Elevating the legs and increasing the rate of intravenous fluid administration are interventions for placental perfusion problems and do not affect cord compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation.
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. What is the likely cause of these late decelerations? 1 Imminent vaginal birth 2 Uteroplacental insufficiency 3 Pattern of nonprogressive labor 4 Reassuring response to contractions
Uteroplacental insufficiency Late decelerations are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both. The imminence of birth cannot be determined from fetal heart rate decelerations, only from cervical dilation. Birth occurs after the cervix has dilated to 10 cm and the fetus has passed through the birth canal. Nonprogressive labor cannot be determined from fetal heart rate decelerations, only from cervical dilation. Late decelerations are not expected, are not reassuring, and must not be ignored.
a prego client is now in the third trimester the client tells the nurse, " I want to be knocked out for this birth" how should the nurse respond? you are worried about too much pain you dont want to be awake during the birth I can understand that because labor is uncomfortable I will tell your healthcare provider about this request
you dont want to be awake during the birth
A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior (ROA) position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? 1 Early first stage of labor 2 Transition stage of labor 3 Beginning second stage of labor 4 Midway through first stage of labor
Correct4 Midway through first stage of labor The cervix is 90% effaced and dilated 6 cm during the active phase of the first stage of labor. When the cervix is dilated 6 cm, the individual is beyond the early stage of labor. Transition is not a stage of labor; it is the last phase of the first stage of labor, which begins when the cervix is dilated 8 cm. The second stage of labor begins when the cervix is fully dilated and 100% effaced.
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action should the nurse implement at this time? 1 Having her pant-blow during contractions 2 Placing her legs in stirrups to facilitate pushing 3 Encouraging her to bear down with each contraction 4 Reviewing the pushing techniques taught in childbirth classes
1 Having her pant-blow during contractions Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.
What is the nurse's priority assessment for a client in the fourth stage of labor? 1 Degree of relaxation 2 Distention of the bladder 3 Extent of breast engorgement 4 Presence of mother-infant bonding
2 Distention of the bladder A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.
A nurse is assessing a primigravida who was admitted in early labor. She is at 41-weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor? 1 Encourage her to watch television. 2 Take a walk around the unit with her. 3 Ask her to maintain a left-lateral position. 4 Promote the patterned, paced breathing technique.
2 Take a walk around the unit with her. Walking may increase the frequency and strength of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.
A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. What is the best response by the nurse to reassure the client? 1 "I'll dilute the medication so it won't have an immediate impact on the baby." 2 "I'll just give a half-dose of the medication while the uterus is in its relaxed phase." 3 "It will be administered during a contraction, when the uterine blood vessels are constricted." 4 "It will be administered in the proximal port of your IV so that you have immediate pain relief."
3 "It will be administered during a contraction, when the uterine blood vessels are constricted." Giving the medication during a contraction, when the uterine vessels are constricted, keeps the medication within the maternal vascular system for several seconds and decreases the impact on the fetus. The other options are incorrect because none of these responses involves administration during a contraction.
While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time? 1 Call the practitioner to prepare for an imminent birth. 2 Turn the mother on her left side to increase venous return. 3 Record the fetal response to contractions and continue to monitor the heart rate. 4 Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.
3 Record the fetal response to contractions and continue to monitor the heart rate Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This is not a fetal heart rate abnormality and does not require a specific amount of time for observation; if the interventions are effective, monitoring should continue as before.
A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I can't take this a minute longer." What does this behavior indicate to the nurse caring for her? 1 There was no preparation for labor. 2 She should receive an analgesic for pain. 3 She is entering the transition phase of labor. 4 Hypertonic uterine contractions are developing
3 She is entering the transition phase of labor. The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.
A client in active labor starts screaming, "The baby is coming! Do something!" What is the nurse's primary action? 1 Notifying the practitioner of the imminent birth 2 Telling the client that it is too soon and encouraging her to pant 3 Checking the perineal area for the presenting part 4 Helping the client hold her knees together and explaining what to expect
Checking the perineal area for the presenting part The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions do what? 1 Decrease when the client walks 2 Are irregular and vary in intensity 3 Come every 5 minutes for an hour 4 Come every 10 minutes for an hour
Come every 5 minutes for an hour Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense.
The nurse is providing care to a multiparous client in active labor. The client is requesting something for the pain. What is the nurse's priority intervention? 1 Examining the client's cervix for dilation and effacement 2 Determining the client's options by assessing the prescriptions in the chart 3 Asking her whether she prefers an epidural or something in her intravenous line 4 Evaluating the fetal monitoring strip to determine the frequency and duration of contractions
Correct1 Examining the client's cervix for dilation and effacement Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.
List the mechanisms of labor in the correct sequence. .Engagement .Descent .Flexion .Internal rotation .Extension .External rotation .Expulsion
The cardinal movements of the mechanism of labor that occur in a vertex presentation are: (1) Descent of the fetal presenting part through the true pelvis. (2) Engagement of the fetal presenting part as its widest diameter reaches the level of the ischial spines of the mother's pelvis. (3) Flexion of the fetal head so that the smallest head diameters pass through the pelvis. (4) Internal rotation to allow the largest fetal head diameters to match the largest maternal pelvic diameters. (5) Extension of the fetal head as it passes beneath the mother's symphysis pubis. (6) External rotation of the fetal head to allow the shoulders to rotate internally to fit the mother's pelvis. (7) Expulsion of the fetal shoulders and fetal body.
While caring for a client during labor, what does the nurse remember about the second stage of labor? 1 It ends at the time of birth. 2 It ends as the placenta is expelled. = 3 It begins with the transition phase of labor. 4 It begins with the onset of strong contractions.
1 It ends at the time of birth. The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
The nurse is preparing a client in active labor for epidural anesthesia. Which prescribed intervention should the nurse initiate before the anesthesiologist initiates the epidural? 1 Application of oxygen at 5 L/min with a face mask 2 Ensuring that naloxone is available on the unit 3 Administering a 500-mL bolus of lactated Ringer solution intravenously 4 Preparing an intravenous infusion of oxytocin (Pitocin) to augment the client's labor
Administering a 500-mL bolus of lactated Ringer solution intravenously Epidural anesthesia blocks sympathetic nerves along with pain nerves, which may result in vasodilation and hypotension. Rapid infusion of a nondextrose IV solution, such as lactated Ringer or normal saline solution, before initiation of the block fills the vascular system to offset vasodilation. Preload quantities are at least 500 to 1000 mL, infused rapidly. Oxygen would only be warranted if a hypotensive episode were to occur after the epidural was administered. Naloxone reverses opioid-induced respiratory depression. With epidural anesthesia the effects on the fetus depend on how the woman responds rather than on direct drug effects. Naloxone, an opioid antagonist, would only be used if it was warranted and delivery was imminent. An oxytocin infusion would not be used unless the contractions became dysfunctional.
Which physiologic alteration does the nurse expect in a client's hematologic system during the second trimester of pregnancy? 1 An increase in hematocrit 2 An increase in blood volume 3 A decrease in sedimentation rate 4 A decrease in white blood cells
An increase in blood volume The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The sedimentation rate increases because of a decrease in plasma proteins. White blood cells count remains stable during the antepartum period.
A woman at 40 weeks' gestation is admitted in active labor. When the client reaches 5 centimeters dilation, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which assessments and interventions should be performed? Select all that apply. 1 Maintaining intravenous fluid administration 2 Having oxygen available in case of hypotension 3 Checking the bladder for distention every 2 hours 4 Positioning the client supine for ease of monitoring 5 Monitoring fetal heart rate and labor progress per hospital protocol 6 Administering an oxytocin infusion to maintain the labor pattern
Correct1 Maintaining intravenous fluid administration Correct2 Having oxygen available in case of hypotension Correct3 Checking the bladder for distention every 2 hours Correct5 Monitoring fetal heart rate and labor progress per hospital protocol Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and also provide a vehicle for emergency drug administration. Oxygen should be available in case of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.
What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? 1 Intrusion on movement 2 Inability to take sedatives 3 Interference with breathing techniques 4 Increased frequency of vaginal examinations
Intrusion on movement Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.
a nurse assess the frequency of the clients contractions by timing them from the beginning of the contraction until when? the uterus starts to relax the end of the second contraction the uterus has relaxed completely the beginning of the next contraction
the beginning of the next contraction