O'Meara Prep U: Ch 16
When collecting data to devise a labor plan for a multiparous woman, which question bestallows the nurse to develop individualized strategies
"Tell me how you handled labor pain in your past deliveries."
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."
When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche
"You had a successful labor and vaginal delivery with your first pregnancy."
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as
-2 station.
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 nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize
Check the chart for the last void.
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
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage
cervical dilation (dilatation)
A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement
"Anxiety can speed up the labor process."
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
A client in labor receiving epidural anesthesia develops hypotension. Which of the following would the nurse do first
Give an intravenous bolus of fluid
The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching
Longitudinal
The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this patient's discomfort
Massage the lower back.
Which assessment findings indicate a distressed fetus? Select all that apply
Persistent bradycardia Late deceleration patterns Absent accelerations
A laboring client is restless and moving frequently in the bed. She appears to be more uncomfortable with the contractions but refuses pain medication when offered. The client's partner has left the room to stretch his legs. Which response by the nurse is most helpful
Stand next to the client at the side of the bed.
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best
Take no extra measures; prepare for a standard labor.
When developing a labor plan with the client, which outcome is the priority
The client will direct her pain management techniques.
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows
descent, flexion, internal rotation, extension, external rotation, expulsion
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
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 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 nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding
lie
A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use
longitudinal
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next
respiratory rate
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 prioritizeat this stage
Practicing effleurage on the abdomen
In which manner is the fetal status best assessed during the active and transition stages of labor
Fetal heart rate at the peak of a contraction
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
Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms
Electrical impulses are created that interfere with nerve transmission.
The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team
Provide care under the supervision of an RN
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign
The urge to push occurs.
A patient arrives at the birthing suite and tells the nurse that she believes she is in labor. Which assessments should the nurse prioritize at this time? Select all that apply
birth imminence fetal status risk factors maternal status
The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding a
frequency.
Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station
0
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 pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position
Long axis of fetus is perpendicular to that of client.
The laboring client who is at 3 cm dilation (dilatation) 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.
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure
allowing the woman time to be alone
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point
counterpressure against the sacrum
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor
decrease in circulation and perfusion to the fetus
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply
determining the position of the fetus determining the lie of the fetus determining the presentation of the fetus
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as
effleurage.
Which intervention would be least effective in caring for a woman who is in the transition phase of labor
encouraging the woman to ambulate
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 labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply
• duration• intensity• frequency
The five "Ps" of labor are
passageway, passenger, position, powers, psych.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem
prolonged decelerations
A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement
Provide emotional and physical support.
