Reproduction 5
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? Apply fundal pressure. Observe for the presence of a nuchal cord. Observe for crowning. Prepare to administer oxytocin.
Fundal pressure is not advised because there is no evidence to support that this action facilitates a safe vaginal birth. An umbilical cord that is wrapped around the neck of the fetus cannot be seen until after the fetal head is delivered. A +3 station indicates that the fetal head is still in the birth canal, crowning may be observed, and delivery of the fetal head is imminent. !!! In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent. There are no data to suggest that labor is delayed or ineffective. Preparing to administer oxytocin is not an appropriate action at this time.
A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? Cut the umbilical cord. Apply perineal pressure to the emerging fetal head. Prevent the perineum from tearing. Promote delivery of the placenta.
Cutting the umbilical cord is not a priority. The cord is clamped and cut after the placenta stops pulsating. It is not uncommon for the umbilical cord to encircle the neck. It is rare for the cord to be wrapped so tightly as to cause hypoxia. If the cord is wrapped around the neck, the cord should be gently slipped over the head. If the loop is too tight, the cord should be clamped twice, and the cord should be cut between the clamps. !!! Using Maslow's hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations. Maternal complications associated with rapid labor and an emergency birth can include uterine rupture, lacerations of the birth canal, and postpartum hemorrhage. Applying perineal pressure as the fetal head is crowning can decrease maternal tearing and injury. However, preventing the perineum from tearing is not the priority concern. This is not the priority action. If a precipitous labor results in emergency birth without the provider being present, the placenta can be left in place until the provider arrives. The nurse should never tug on the cord. Inappropriate traction can tear the cord, separate the placenta, or invert the uterus. Signs of placental separation include a slight gush of dark blood, lengthening of the cord, and change in the shape of the uterus.
A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? Monitor the client's temperature. Assess the fetal heart rate. Assess the odor of the amniotic fluid. Provide clean, dry underpads.
The client's temperature should be checked at least every 2 hr following the rupture of the membranes, but this is not the priority action by the nurse. !!! The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes. The nurse should assess the odor, color, and consistency of the amniotic fluid, but this is not the priority action by the nurse. The nurse should provide clean, dry underpads following the amniotomy, but this is not the priority action by the nurse.
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? Maintain the client in the lithotomy position. Perform vaginal examinations frequently. Remind the client to bear down with each contraction. Encourage the client to empty her bladder every 2 hr.
The lithotomy position is commonly used during delivery. With this position, the client reclines, and her legs are placed in stirrups. This client is only in the first stage of labor, so this would not be an appropriate position at this time. In addition, the client is encouraged to change positions during the labor process because this can relieve fatigue, increase comfort, and improve circulation. Vaginal examination can introduce microorganisms into the vagina that can ascend into the amniotic sac. Frequent vaginal examinations after rupture of membranes increases the risk of infection and should be limited. A client in labor should not be encouraged to push or bear down until the cervix is completely dilated. This client is in the active phase of the first stage of labor. This means that her cervix will be between 0 and 7 cm dilated. It would not be appropriate to have her to push or bear down at this time. !!! A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? Expulsion of a blood-tinged mucous plug Continuous contraction lasting 2 min Pressure on the perineum causing the client to bear down Expulsion of clear fluid from the vagina
This is an expected finding. The provider will want to know that the client expressed the plug, but it does not warrant immediate notification. !!! A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately. This is an expected finding. The provider will want to know that the client wants to bear down and the nurse should discourage it in the early stages of labor, but it does not warrant immediate notification. This is an expected finding. The provider will want to know that the client's membranes ruptured, but it does not warrant immediate notification.
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? Elevate the client's legs. Monitor vital signs every 5 min. Notify the provider. Place the client in a lateral position.
The nurse should elevate the client's legs if there is no improvement in the blood pressure with the client in a lateral position, but this is not the priority nursing action. The client's vital signs should be monitored every 5 min, but this is not the priority nursing action. The provider should be notified, but this is not the priority nursing action. !!! Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? Have the client stand at the bedside with her arms at her side. Administer a 500 mL bolus of 5% dextrose in water prior to induction. Inform the client the anesthetic effect will last for approximately 6 hr. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.
The nurse should position the client in a sitting or side-lying position with her back curved to widen the intervertebral space. If the client is to receive a fluid bolus, dextrose solutions should not be used as this can contribute to neonatal hypoglycemia. The nurse should inform the client that the anesthetic effect will last 1 to 3 hr. !!! The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? The fetal head is in the left occiput posterior position. The largest fetal diameter has passed through the pelvic outlet. The posterior fontanel is palpable. The lowermost portion of the fetus is at the level of the ischial spines.
This describes a reference point of the fetal head in relation to the maternal pelvis, indicating a vertex presentation with the fetus in an attitude of general flexion. The pelvic outlet is the lower border of the true pelvis. When the largest fetal diameter has passed through the outlet, the station is greater than zero. This is a clinical finding indicating that the fetal lie is longitudinal with the fetus in an attitude of general flexion. !!! The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? Contractions lasting longer than 90 seconds Contractions occurring every 3 to 5 min Contractions are strong in intensity Client reports feeling contractions in lower back
!!! A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider. In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding. This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider. This is an expected finding in a client who is in true labor. As the labor progresses, the contractions radiate to the abdomen.
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? Rupture of the membranes Changes in the cervix Station of the presenting part Pattern of contractions
The membranes can rupture spontaneously long before the onset of labor. !!! Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor. A client who is a primigravida will typically engage before labor and can enter labor at -1, 0, or even +1 station. A client can have regular contractions for a significant period of time prior to the onset of true labor.
