OB Chapter 14: Nursing Management During Labor and Birth
The pregnant client is planning to hire a doula for support during labor. What statement by the client requires follow-up by the nurse?
My doula will help me with contractions so I will not need any pain relief in labor.
During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern?
Uterine fundus palpated to the right of the umbilicus
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?
110 to 160 bpm
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?
Have the client pant and blow through the contraction.
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?
Palpate the mother's radial pulse at the same time.
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 finding?
less anxiety
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?
This may prolong labor and increase complications.
Is the following statement True or False? If a pregnant woman in labor calls the health care facility, the nurse should strongly advise the woman to come to the facility to be evaluated. a. Trueb.
False
Is the following statement True or False? Pain experienced by a woman in labor is fairly intense. a. Trueb.
False Pain during labor is a universal experience, but the intensity varies
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?
respiratory depression
The client may spend the latent phase of the first stage of labor at home unless which occurs?
The client experiences a rupture of membranes
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?
administration of oxygen by mask
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?
"The baby is coming. I'll explain what's happening and guide you."
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?
Vaginal examination
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
Clear to straw-colored fluid
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?
Assess fetal heart rate.
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.
uterine resting tone frequency of contractions intensity of contractions
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
Fetal status
When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every:
15 to 30 minutes
A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?
"Our baby will come out face first."
When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?
"You have no trouble walking around and using the bathroom after you receive the epidural."
The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief?
A pudendal block
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?
Acceleration of at least 15 bpm for 15 seconds
A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver.
The labor nurse reports to the nurse on the oncoming shift, "The woman in labor room 2 is handling her pain very well. She smiles whenever I go in to talk to her, and she doesn't complain at all!" What assessment by the oncoming labor nurse would best reveal if the off-going labor nurse's observations were correct?
Asking the woman to describe her pain and rate it on a scale of 0 to 10
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman.
The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor?
Attention focusing
The nursing instructor is conducting a class discussion on the various agents used during labor and delivery to assist the client. The instructor determines the class is successful after the students correctly choose which factor as true about the use of systemic analgesia?
Benzodiazepines enhance pain relief attained with opioids and cause sedation.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
Change the position of the client.
During the second stage of labor, assessment would include which of the following?
Complaints of rectal or perineal pressure
A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?
Continue to massage the client's fundus.
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?
Continue with the admission assessment
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?
Continuous labor support
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?
Dilation (dilatation) of cervix
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?
Effleurage
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?
Encourage her through the contractions, explaining why she cannot receive any pain medication.
According to the ACOG, ICSI, and AWHONN guidelines, how often should the fetal heart rate be assessed for a high-risk laboring woman during the second stage of labor?
Every 5 minutes
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Green-colored fluid in the vagina
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?
Help the woman change positions.
The nurse is monitoring the electronic fetal heart rate monitor and notes the following: variable V-shaped decelerations in the fetal heart rate (FH)R lasting about 30 seconds, accelerations of about 5 beats/min before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize?
Help the woman change positions.
A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?
Initiate the technique only when the client is in active labor.
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?
Inspect the perineum.
There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?
It can be administered by the nurse.
The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?
On the uterine fundus
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?
Pain originates from the cervix and lower uterine segment.
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?
Placing a wedge under the hips
A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes?
Provide supplemental oxygen.
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?
Support the client's decision and call the provider.
When managing a client's pain during labor, nurses should:
Support the client's decisions and requests
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.
Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.
Patterned breathing techniques used in labor provide which benefits? Select all that apply.
conscious relaxation distraction pain relief without special tools
The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate?
document this as indicating a normal pattern
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes
The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate (FHR) with the Doppler at least how often?
every hour
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?
external electronic fetal monitoring
A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?
fetal back
A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply.
fetal bradycardia sinusoidal pattern recurrent late decelerations
By the end of the second stage of labor, the nurse would expect which of the following events? The
fetus is born and on the mother's chest
During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?
ischial spine
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?
"The fever may be due to the epidural."
Which of the following practices would not be included in a physiologic birth?
Early induction of labor <39 weeks' gestation
General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?
Neonatal depression is possible.
A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering?
antiretroviral
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR.
A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?
general anesthesia
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?
naloxone
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status
Which assessment findings of the fetus during labor are normal? Select all that apply.
Variability between 18-20 bpm Fetal heart baseline of 130 bpm
At what time is the laboring client encouraged to push?
When the cervix is fully dilated
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?
6.5
A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response?
"Spinal headache is not a usual complication of epidural blocks."
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
Inability to push
Which neonatal assessment is the highest priority if the mother received meperidine during labor?
Respiratory rate
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant.
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
The pain of labor is influenced by many factors. What is one of these factors?
The woman is prepared for labor and birth.
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?
Practicing effleurage on the abdomen
When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing?
Wait until you feel the urge to push.
The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first?
Assess blood pressure.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?
Assess fetal heart rate for fetal safety.
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
Assess for labor progression.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
Assess the amount of cervical dilation (dilatation).
At which time in a client's labor process would the nurse encourage effleurage?
During the early labor phase
A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension?
Ephedrine
The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply.
pruritis hypotension respiratory depression
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
"The injection is given in the space outside the spinal cord."
During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used.
-4 station -2 station 0 station +2 station +4 station
The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby?
1 cm below the ischial spine.
A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?
FHR
While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?
FHR fluctuates from 6 to 25 beats per minute.
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?
Massage the woman's back.
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions.
A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure?
To prevent supine hypotension syndrome
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?
Use a birthing ball and find a position of comfort.
The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes, which nursing action is required?
Utilize a wedge under one hip
The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?
acupressure
A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal?
clear
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage.
A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?
encouraging the client to push when they have a strong desire to do so
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?
every 30 minutes
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
Massage is an effective nonpharmacologic technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism?
increasing the release of endorphins
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?
rupture of membranes
A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply.
spinal abnormality hypovolemia coagulation defects
