OB: Chapter 14 Nursing Management During Labor and Birth

A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states:

"Breathing patterns are distraction techniques taught to decrease pain in labor." Breathing techniques are largely distraction techniques taught in birth classes and are well documented to decrease pain in labor. pg 471

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain." Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor. pg 470

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?

"I respect your preference whether it is to have medication or not." Individualizing care to meet women's specific needs is a nursing responsibility. pg 464

A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?

"It relieves pressure on the fetal head." An episiotomy widens the vaginal opening, decreasing pressure on the fetal head. pg 483

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 Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner. pg 452

A woman who has just been admitted in labor indicates that her husband is parking the car and her doula is on her way. The nurse's best response would be:

"OK, let me ask you some personal questions before she arrives." Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A nurse would want to ask the client any personal questions before the doula arrives because the primary purpose of the doula is to be a continuous presence. A doula does not take the place of a nurse.

A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response?

"Spinal headache is not a usual complication of epidural blocks." Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

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." An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.pg 474

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." Epidural anesthesia impairs mobility; most clients are placed on bed rest after epidural anesthesia is given. Urinary catheterization is frequently required.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. It would be most appropriate to meet which criterion?

"Your labor signs have not changed; we are looking for changes in your labor pattern before we check you again." The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The client has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her. pg 451

What is the normally accepted fetal heart rate range?

110-160 bpm The standard acceptable fetal heart rate baseline is the range of 110-160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be most likely?

164 beats per minute A fetal heart rate of 164 beats per minute (bpm) indicates fetal tachycardia. The normal range of FHR is between 120 and 160 bpm. When the FHR is above 160 bpm, it should be considered as fetal tachycardia. Therefore, a FHR of 164 beats per minute is considered tachycardia.

A client has just received IV sedation. What must the nurse tell the client to do?

Ambulate only with assistance from the nurse or caregiver. The client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary. pg 475

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 amount of cervical dilation. If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment. pg 451

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. Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated. pg 451

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, this nursing assessment should be performed first.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels light-headed and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask. In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler's position owing to risk of supine hypotension in the supine position and in Trendelenburg's position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.

The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded, distended, and nontender. What intervention should the nurse take next?

Check the chart for the last void. The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be taken care of by the nurse. The client 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. pg 486

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication?

Continuous support through the labor process helps decrease the need for pain medication. Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication. pg 465

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

Determine if the client is in true or false labor. When a nurse first comes in contact with a pregnant client, it is important to first ascertain whether the woman is in true or false labor. Information regarding the number of pregnancies or history of drug allergy is not important criteria for admitting the client. The healthcare provider should be notified once the nurse knows the client's current status. pg 478

The client is in the second stage of labor and is at 2+ station and in anticipation of birth within the hour. Her epidural did not work, and she is begging for meperidine. Which is the most appropriate action by the nurse?

Encourage her through the contractions, and explain why she is not receiving the meperidine. At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

How does a woman who feels in control of the situation during labor influence her pain?

Feelings of control are inversely related to the client's report of pain. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control. pg 475

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips. For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-pace breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every three breaths is not recommended in any of the three levels of patterned breathing.

A multigravida is admitted to the hospital in active labor. The client's and the fetus's condition have been good since admission. The client calls out to the nurse, "the baby is coming!" What is the first action of the nurse?

Inspect the perineum. The nurse needs to determine if birth is imminent and be prepared for birth. Once the nurse assesses the coming labor, the heart sounds, contraction rate, and contacting the primary care provider can all be done, if there is time.

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 has the ability to be administered by the nurse Opioids are most frequently given by the intravenous (IV) route because this route provides fast onset and more consistent drug levels than do the subcutaneous or intramuscular routes.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable. The best position for all women during labor is on their side.

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?

Massage the woman's back. 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.

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. General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation. pg 476

A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"?

Palpate the area above the symphysis pubis every two hours. Another source of trauma that can interfere with the progress of labor is a full bladder. Every two hours the nurse should palpate the area just above the symphysis pubis feeling for a rounded area of distention, which indicates the bladder is full. pg 481

A woman in labor at the hospital has just received an epidural block. Which intervention is a priority before and during epidural placement?

Provide adequate IV fluids to maintain her blood pressure. The client will need to have a bolus of IV fluids prior to and then maintained during the epidural to be prepared in the event of the hypotensive episodes that may accompany epidural placement. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature, but wait for instructions from the primary care provider as to when to administer medication. Bradycardia is not a common side effect of epidural medication. pg 474

A nurse is caring for a female client in labor who has chosen hydrotherapy as her pain management for labor. As the nurse prepares the client for this treatment, which procedure is recommended as the most appropriate consideration?

The client should be in active labor. Most recommendations for hydrotherapy, or water therapy, include active labor. If the client is not in active labor, the contractions could slow because of relaxation of muscles. There is no time limit for water therapy; it is provided for comfort. The water temperature should not be higher than the maternal body temperature, and water therapy can be used with intact or ruptured membranes.

A client has just arrived at the hospital, in early labor, showing signs of extreme anxiety over the birth to come. Why is it so important that the nurse help the client relax?

The client's anxiety can actually slow down the labor process and decrease the amount of oxygen reaching the uterus and the fetus. Anxiety out of control can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and have a negative impact on the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural. It is premature to be stern with the client. While it is preferable that she save her energy, it is not damaging to her or to the fetus if she does not sleep. pg464

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

This is a technique to prevent the painful stimuli from entering the brain. Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. pg 465

The laboring client who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia 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. Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. pg 471

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 most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression. pg 463

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. Research has shown that women report higher levels of satisfaction with their labor experience when they feel a high degree of control over the experience of pain (Stuebe & Barbieri, 2005). pg 464

The expected fetal heart rate response in an active fetus is:

acceleration of at least 15 bpm for 15 seconds. 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.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction pg 453

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 Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes is a classic example of therapeutic touch. Biofeedback is based on the belief people have control and can regulate internal events such as heart rate and pain responses. pg 465

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 client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation. pg 460

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 Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation. pg 470

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. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

A woman is experiencing back labor and reports intense pain in the lower back. Which is the most effective nursing intervention to relieve this type of pain?

counter pressure against the sacrum Counter pressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as is conscious relaxation. Breathing will not diminish the pain of back labor. pg 483

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding. pg 473

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency?

every 15 minutes It is recommended that the FHR be assessed during the second stage of labor every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage.

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage. Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain. pg 470

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation. pg 481

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 substance is the nurse referring?

endorphins 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. pg 468

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 During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour. pg 491

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 Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through ultrasonography or abdominal palpation but is not indicative of fetal oxygenation. pg 455

As a woman enters the second stage of labor, which would the nurse expect to assess?

feelings of being frightened by the change in contractions The nature of contractions changes so drastically to an urge to push that this can be frightening. pg 487

A pregnant client in her 32nd week of gestation has been admitted to a health care center reporting decreased fetal movement. What should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?

fetal back 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. pg 453

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 General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

A client is being admitted to labor and birth. When admitting an obstetric client in early labor, the first intervention by the nurse is:

good rapport is established with the client and significant other. On admission the client and her family need to establish a rapport with their caregiver. If the client is stable and there is no immediate need, rapport should be established over actions that can be taken care of later.

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 The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

The nurse is assisting a client through labor, monitoring her closely, now that she has received an epidural. The nurse would report which finding to the anesthesiologist?

inability to push If she is not able to push, her epidural dose may be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

instruct the client or her partner to perform light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique. pg 465

At which time during a woman's labor might the nurse assist with a pudendal block?

just before birth Pudendal block is a local block in the perineal area and is used to numb for birth. Application before labor begins or while it is in the early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over

The student nurse is preparing to assess the fetal heart rate (FHR). She 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 best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant. pg 455

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

A nurse is caring for a client who has just received an epidural. Which side effect is the most common in epidural anesthesia?

maternal hypotension, which can lead to fetal bradycardia Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. pg 474

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid?

naloxone Naloxone is an opioid antagonist that can be given to reverse the effects of the central nervous system depression, including respiratory depression, caused by opioids. It is also used to reverse the side effects of neuraxial opioids. Nalbuphine is an opioid. Hydroxyzine is an ataractic. Midazolam is a benzodiazepine. pg 473

A client has presented in the early phase of labor. She is experiencing abdominal pain and shows signs of growing anxiety about the pain. What is the best pain management technique the nurse can suggest at this stage?

practicing effleurage on the abdomen In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with gate theory. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor. pg 465

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 Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural headache are all side effects of a spinal epidural block.

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression. pg 474

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs. pg 491

A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?

taking her blood pressure and determining whether clonus or edema is present In advanced labor the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next. Measuring from the beginning of one contraction to the next marks the time between contractions. pg 453

On examination, the nurse determines the client is at 50% effacement. This means:

the cervical canal is 1 cm long. Effacement refers to the length of the cervical canal. At 0%, the cervical canal is 2 cm long; at 50%, 1 cm long; and at 100%, the cervical canal is obliterated.

A woman's perception of pain can differ according to all of the following except:

the presentation, lie, and attitude of the fetus. Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.

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 should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.

While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:

uteroplacental insufficiency. 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.

Opioids are often used in labor for pharmacologic pain management. A client in the transition phase of labor is requesting fentanyl for pain. How should the nurse respond to her request?

"Pain medication given now might cause the baby to have slow respirations and is not recommended; let's try to focus and breathe." Once the woman has entered into the transition phase of labor, she is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress. pg 464

A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement?

Change maternal position to an upright or side lying position. To intervene with late decelerations, the nurse should change maternal position to an upright or side lying posture. Late deceleration in the fetus indicates insufficient uteroplacental perfusion. Changing the maternal position improves the maternal venous return. In upright position, the uterine activity becomes more efficient. Attempts should be made to increase the uteroplacental perfusion and fetal circulation. Administering oxytocin and encouraging Valsalva maneuver (extended breath holding) may augment the uteroplacental insufficiency. In late deceleration, the nurse should administer oxygen through nasal cannula and discontinue administration of oxytocin. Placing the client in the lithotomy position contributes to poor placental circulation pg 463

The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?

Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate. pg 460

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 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 finding?

less anxiety 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.

A client received IV meperidine for pain. An hour later a full-term neonate is born with respiratory depression. The nurse anticipates the neonate will require administration of which medication?

naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor. pg 471