Chapter 13: Nursing Care During Labor and Birth – Flashcards

ANS: C Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

ANS: A The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

ANS: A The second Leopold's maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.

ANS: D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn's transition to extrauterine life.

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem.

ANS: B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

ANS: C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell's sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

ANS: A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the patient's left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

ANS: D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient's urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

ANS: B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body's signals. A brief slowing of contractions often occurs at the beginning of the second stage.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C [100.4° F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

0.75

B A gush or trickle of fluid from the vagina should be evaluated as soon as possible. Waiting until the contractions are 5 minutes apart is appropriate for a primigravida if the membranes have not ruptured.

C Assessment priorities on admission of a labor client are to determine the condition of the mother and fetus and whether birth is imminent. Checking the fetal heart rate is one of the first assessments that should be carried out. Along with assessing the fetus, the nurse should also check the maternal blood pressure and temperature.

A Bright red bleeding is a sign of complications, and the physician or primary health care provider should be notified immediately. Vaginal exams or enemas are contraindicated in the presence of bleeding. Continuing to monitor the mother and fetus is important after notifying the health care provider.

A A station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of 0 would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Passage through the ischial spines with internal rotation would be indicated by a plus station, such as +1. Progress of effacement is referred to by percentages, with 100% indicating full effacement, and dilation by centimeters (cm), with 10 cm indicating full dilation.

C The client may not be able to determine true from false labor; however, she should be made aware of what signs to look for that may indicate the need for evaluation.

B The heart rate less than 100 bpm gets a score of 1, a lusty cry will give a score of 2 for both respiratory effort and reflex response, the flexed posture and vigorous movements gives a score of 2, and the bluish coloration of the hands and feet will give a score of 1.

B Even though the fundus is firm, it is not midline and the bladder is filling. A full bladder will interfere with contractions of the uterus and lead to increased bleeding. The rest of the answer choices are within normal limits for this stage.

A, B, C, F

A, B, C By 48 hours postpartum, mothers are expected to be on oral pain medication.

A, B, C, D

A, B

Delayed pushing, laboring down, rest and descend, or passive pushing