Intrapartum – Flashcards

While caring for a pregnant patient with body mass index of 32 during labor, the nurse observes that the second stage of labor lasts for about 11 minutes. The nurse also finds that the expected birth weight of the fetus is around 4200 g. Which complication does the nurse anticipate in the neonate after birth? Correct1 Erb palsy 2 Klumpke palsy 3 Strawberry hemangioma 4 Erythema toxicum neonatorum Maternal body mass index of greater than 30, a second stage of labor lasting less than 15 minutes, and an infant birth weight higher than 4000 g indicates a risk of Erb palsy or Erb-Duchenne paralysis in the neonate. Klumpke palsy can result due to severe stretching of the upper extremities, while the trunk is relatively less mobile during labor. A maternal body mass index greater than 30, a second stage of labor lasting less than 15 minutes, and infant birth weight higher than 4000 g are not indicators of strawberry hemangioma or erythema toxicum neonatorum.

A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform these interventions? Correct Calling for help will allow all other actions to be completed more quickly. This is especially critical during an emergency situation. Next the nurse should assess the fetal heart tones to identify the effect of the bleeding on the fetus, because the fetus often shows signs of distress before the mother does. After checking the fetal heart tone the nurse should increase the IV infusion rate, which should take only seconds and can have a significant effect on circulation. Oxygen can be instituted after the IV infusion rate has been increased; this will be of benefit to both mother and fetus. Calling the primary health care provider is important, but instituting lifesaving measures takes precedence.

The nurse is caring for a patient that has just had an amniotomy performed by the health care provider. The fetal heart rate immediately decreased from 140 to 80 beats/min. What is the priority nursing action? Correct1 Inspecting the vagina 2 Administering oxygen Incorrect3 Increase the intravenous fluids 4 Placing the client in the knee-chest position Follow your nursing process and begin with assessment of the cause of the deceleration, which is likely to be a prolapsed cord due to the recent history of an amniotomy. Inspection is performed to identify the cause for the decreased fetal heart rate; a cord prolapse requires immediate removal of the presenting part from the cord. Oxygen may be administered later, but this is not the priority. Increasing the intravenous fluids is not the priority at this time. Placing the client in the knee-chest position is an intervention that can be implemented once it is determined that the umbilical cord is prolapsed. It relieves pressure on the cord, which increases the flow of oxygen and nutrients to the fetus.

A pregnant client is now in the third trimester. The client tells the nurse, "I want to be knocked out for the birth." How should the nurse respond? Incorrect1 "You are worried about too much pain." Correct2 "You don't want to be awake during the birth." 3 "I can understand that because labor is uncomfortable." 4 "I will tell your health care provider about this request." Paraphrasing encourages the client to express the rationale for this request.Suggesting the client is worried about pain expresses an assumption without enough information. Saying labor is uncomfortable may increase the client's anxiety. Although this request should be forwarded to the health care provider, the reason for the choice of general anesthesia should be explored.

A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. What does the nurse suspect as the cause of this change? Incorrect1 Fetal acidosis Correct2 Prolapsed cord 3 Head compression 4 Uteroplacental insufficiency This variable pattern with bradycardia is an ominous sign; it is indicative of cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis occurs with uteroplacental insufficiency, not in response to a prolapsed cord. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia are associated with uteroplacental insufficiency, not a prolapsed cord.

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action? Correct1 Notifying the health care provider Incorrect2 Resuming continuous fetal heart monitoring 3 Continuing to monitor the maternal vital signs 4 Documenting the fetal heart rate as an expected response to contractions Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous; the fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.

A client having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the last two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. What type of pattern is this? 1 Bradycardia Correct2 Late decelerations 3 Early decelerations Incorrect4 Variable decelerations Late decelerations begin during the peak of a contraction and continue after the contraction has ended. Bradycardia is a fetal heart rate slower than 110 beats/min for 10 minutes. Early decelerations mirror the contraction, beginning at the start of the contraction and ending when the contraction is over. Variable decelerations fall and rise abruptly and do not have the uniform appearance noted with early and late decelerations.

A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time? 1 Checking cervical dilation every hour 2 Keeping the labor environment dark and quiet Correct3 Infusing oxytocin by piggybacking into the primary line Incorrect4 Positioning the client on the left side throughout the infusion Piggybacking the oxytocin (Pitocin) infusion allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV. Cervical dilation is checked when there is believed to be a change, not on a regular basis. Unless specifically requested by the client, there is no reason to maintain a dark, quiet labor environment. Although positioning the client on her left side is recommended, it is not the primary concern at this time; there are no data to indicate maternal hypotension.

A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a nonreassuring outcome? Correct1 Late 2 Early 3 Baseline Incorrect4 Variable The fetus with a borderline cardiac reserve will show hypoxia, evidenced by a decreased FHR with minimal stress, making the test positive. Early decelerations, a response to head compression, are benign. "Baseline" is not used to describe the baseline measurement; the baseline rate is determined before the test or early in the test to provide a basis for comparison, not to indicate fetal compromise. Variable decelerations are nonuniform drops in FHR before, during, or after a contraction; these are related to partial, brief cord compression that can be eliminated with a change in the mother's position.

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? Correct1 Assessing maternal vital signs Incorrect2 Planning for an emergency birth 3 Administering oxygen by way of nasal cannula 4 Preparing for fetal scalp blood sampling A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high flow oxygen via non-rebreather if there is a non-reassuring assessment of the external monitoring, which is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored? 1 Sinus tachycardia 2 Urinary frequency Incorrect3 Respiratory distress Correct4 Hypotensive episodes Epidural anesthesia creates a sympathetic block that causes loss of peripheral vascular resistance and a decrease in venous return; this leads to a reduced cardiac output, which can precipitate hypotensive episodes. Bradycardia, not tachycardia, may result. The urge to void is diminished with epidural anesthesia; the client should be encouraged to void to prevent distention. Respiratory distress is not a common side effect of epidural anesthesia; it may occur if an accidental high placement of anesthetic occurs or an excessive amount of anesthesia is administered.

A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next? Correct1 Changing the client's position 2 Taking the client's blood pressure 3 Stopping the client's oxytocin infusion Incorrect4 Preparing the client for an immediate birth Variable decelerations are usually a result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure and are not oxytocin related. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? Incorrect1 Above the umbilicus in the midline 2 Above the umbilicus on the left side Correct3 Below the umbilicus on the right side 4 Below the umbilicus near the left groin

A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? 1 It is the policy of the institution to provide 2 bags of lactated Ringer's solution. Correct2 There is a risk of hypotension, and the large amount of IV fluid reduces the risk. 3 Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink. Incorrect4 The client must be given 500 mL of fluid to ascertain that the line is working so that medication may be administered. There is a risk of hypotension (low blood pressure), which may cause fetal distress, with epidural anesthesia. With the administration of 500 to 2000 mL, the risk is reduced. A large amount of intravenous fluid is a source of hydration, but this response does not explain the necessity of hydrating the client before the procedure. Providing 500 mL of fluid is useful in counteracting the risk of hypotension, but it is not given as a means of determining that the line is working before the administration of medication. Epidural medication is administered through a catheter placed by the anesthetist. Quoting institutional policy does not provide the explanation for administering the solution.

During labor an internal fetal monitor is applied. What fetal heart rate (FHR) should most concern the nurse? 1 One that does not slow during contractions 2 One that ranges from 130 to 140 beats/min Incorrect3 One that drops to 110 beats/min during a contraction Correct4 One that returns to baseline after a contraction ends A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 beats/min during a contraction, known as an early deceleration, is the result of fetal head compression during a contraction; the FHR returns to baseline at the same time that the contraction ends.

External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action? 1 Notifying the health care provider of possible head compression 2 Placing the client in a knee-chest position to avoid cord compression Incorrect3 Putting the client in a dorsal recumbent position to prevent compression of the vena cava Correct4 Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends The reading noted by the nurse represents early decelerations that occur with head compression during a contraction, with the fetal heart rate (FHR) returning to baseline at the end of the contraction. Head compression and cord compression are both common occurrences during a contraction; intervention is unnecessary if the FHR returns to baseline at the end of the contraction. The dorsal recumbent position will increase pressure on the vena cava and is contraindicated.

During the first hour after a cesarean birth, a nurse notes that the client's lochia has saturated one perineal pad. In light of the knowledge of expected lochial flow, what should the nurse conclude that this indicates? 1 Scant lochial flow Incorrect2 Postpartum hemorrhage 3 Retained placental fragments Correct4 Lochial flow within expected limits It is expected that as many as two perineal pads will be saturated in the first hour. A scant flow probably would not saturate even one pad. Hemorrhage would saturate more than two pads in 1 hour. Retained placental fragments would be accompanied by heavy bleeding and require more than two pads during the first hour.

The nurse is caring for a client who is in the first stage of labor. The fetal heart rate monitor displays an irregular baseline that was in the 150s and is now in the 130s with variability. What is the priority nursing intervention? 1 Administering oxygen 2 Notifying the practitioner Incorrect3 Changing the client's position Correct4 Continuing to monitor the client This is an expected occurrence caused by the interplay of the sympathetic and parasympathetic nervous systems. Because this is an expected response, there is no need to administer oxygen, notify the practitioner, or change the client's position.

A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear and the fetal heart rate is stable. What does the nurse anticipate? 1 A prolonged second stage of labor Incorrect2 A difficult birth resulting from delayed effacement Correct3 Birth of the fetus within a day 4 The stimulation of labor with an oxytocin infusion In an uneventful full-term pregnancy, birth usually occurs within 24 hours after membranes have ruptured. If the birth does not occur within this time frame, both the mother and fetus will be exposed to sepsis and labor will probably be stimulated by the health care provider. There is no relationship between ruptured membranes and the second stage of labor. There are no data to indicate that effacement is delayed. Although it may be done eventually, it is too early to anticipate that labor will be stimulated.

The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department reveals that her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival? Incorrect1 Settle the client in bed and attach an external fetal monitor. 2 Have the client undress while taking her history from her partner. Correct3 Introduce the staff nurses to the couple and try to make them feel welcome. 4 Ask the couple to wait in the examining room while notifying the health care provider. The client is in the first stage of labor; she and the fetus were assessed earlier, and both are stable. At this time the priority of care is the establishment of a trusting relationship with the client and her partner. This will help allay their anxiety. Putting the client in bed and attaching an external fetal monitor may be necessary later; however, it is not the priority. The history should be taken from the client as long as she is capable of providing it. Asking the couple to wait in the examining room while notifying the health care provider is not a priority; the provider may have been notified already.

A nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? 1 Calling the practitioner Correct2 Changing the maternal position Incorrect3 Obtaining the maternal blood pressure 4 Preparing the environment for an immediate birth The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiological response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.

The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum? 1 Small tears 2 Greenish-yellow amniotic fluid Correct3 Enlarging area of caput with each contraction Incorrect4 An increasing amount of amniotic fluid with each contraction The client should be pushing with each contraction; with the head at +3 station, each push will bring more of the caput into view at the vaginal opening. It is too early for the perineum to be stretched to the point of tearing; if this should occur later, an episiotomy may be performed. Meconium is discoloring the amniotic fluid; it is an unexpected finding that may indicate that the fetus is at risk. There is a decreased, not an increased, amount of amniotic fluid at the end of labor.

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client? 1 Hypertension Correct2 Urine retention Incorrect3 Subnormal temperature 4 Decreased level of consciousness Anesthesia blocks the sensory pathways; therefore the mother does not sense bladder distention and may be unable to void. Hypotension, not hypertension, is a side effect of epidural anesthesia. An epidural anesthetic does not influence body temperature. A decreased level of consciousness occurs with general anesthesia, not epidural anesthesia; general anesthesia is used when there is an emergency.

When assessing a newly admitted primigravida in active labor, the nurse hears the fetal heartbeat loudest in the upper left quadrant. The nurse concludes that the position of the fetus is left: Correct1 Sacral anterior 2 Mentum anterior Incorrect3 Occipital posterior 4 Occipital transverse If the heart is heard in the upper left quadrant, the fetus is lying in a breech presentation with the head upright and the heart uppermost. Fetal heart tones are heard best in the lower quadrants of the abdomen in cephalic presentations.

A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks' gestation. Which condition is a contraindication to the use of oxytocin (Pitocin) induction? Incorrect1 Chorioamnionitis 2 Postterm pregnancy Correct3 Active genital herpes infection 4 Hypertension associated with pregnancy Oxytocin is not administered when a woman has an active genital herpes infection. In this case, the baby would be delivered by means of cesarean section to help keep it from being infected during birth. Chorioamnionitis, hypertension associated with pregnancy, and postterm pregnancy are all indications for the use of oxytocin induction.

Two days after delivery a client has a temperature of 101° F (38.3° C), general malaise, anorexia, and chills. What does the nurse expect to identify on the client's laboratory report? 1 Increased hemoglobin level Incorrect2 Decreased C-reactive protein Correct3 Increased white blood cell (WBC) count 4 Right-shift differential WBC count An increased WBC count is indicative of an infectious process. In postpartum clients hemoglobin values usually decrease because of the typical blood loss during the birth process. C-reactive protein is increased during an infectious process. A right-shift differential WBC count occurs in clients with liver disease and pernicious anemia; a shift to the left occurs in an infectious process and is related to an increase in immature neutrophils.

Several hours after delivery, a new mother expresses ambivalence about her infant. How will the nurse promote bonding between this mother and her newborn? Correct1 Having the mother feed the infant 2 Removing the infant from the mother's arms if it cries Incorrect3 Positioning the infant so its head rests on the mother's shoulder 4 Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant Feeding the infant promotes bonding through physical interaction, and positioning the infant in a face-to-face position facilitates eye contact. Removing the infant decreases the pair's time together. Positioning the infant on the mother's shoulder prevents the face-to-face contact that promotes bonding. It is important to have the parent and infant interact as soon as possible after birth to promote bonding.

A 37-year-old client with type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate a need for the NST? Select all that apply. Incorrect1 Age greater than 35 years 2 The risk for placenta previa Correct3 The risk for placental insufficiency Correct4 A history of stillbirth from her last pregnancy Correct5 Maternal history of hypertension Pregnant women with diabetes are prone to placental insufficiency, which can threaten fetal well-being. In addition, history of stillbirth is also an indication for NST. In addition, maternal conditions that can affect placental perfusion such as hypertension is an indication for a NST. Advanced maternal age alone is not an indicator for an NST; although advanced maternal age increases the risk of placenta previa, it is not the primary reason for having an NST.

A client at 37 weeks' gestation is in active labor. Her contractions are now 2 to 3 minutes apart and lasting approximately 60 seconds. The fetal heart rate (FHR) averages around 100 beats/min between contractions. What should the nurse do next? Correct1 Notify the primary health care provider. 2 Monitor the fetal heart rate continuously. Incorrect3 Check the client's perineum for a prolapsed cord. 4 Document the findings in the client's medical record. Bradycardia of 100 beats/min may be a benign finding caused by a vagal response to prolonged head compression or a sign of progressive fetal hypoxia and acidosis. The primary care provider should be notified of the baseline FHR and variability. Monitoring should be continued to determine the cause of the bradycardia, and then the nurse should act accordingly. Although monitoring should be continuous, the practitioner should be informed of the bradycardia. There is no evidence that the client's membranes have ruptured, necessitating this observation. The expected fetal heart rate between contractions is 110 to 160 beats/min; simply documenting the findings is inadequate.

A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply. Correct1 Maintaining intravenous fluid administration Correct2 Having oxygen available in case of hypotension Correct3 Checking the bladder for distention every 2 hours 4 Positioning the client supine for ease of monitoring Correct5 Monitoring fetal heart rate and labor progress per hospital protocol Incorrect6 Administering an oxytocin (Pitocin) infusion to maintain the labor pattern Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and also provide a vehicle for emergency drug administration. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. Oxygen should be available in case of hypotension occurs as a result of to the epidural block or as emergency care should the anesthetic agent migrate upward. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform these interventions? Correct 1. Call for help. Incorrect 2. Increase the maintenance IV infusion rate. Incorrect 3. Start oxygen at 8 L/mask. Incorrect 4. Call the health care provider. Incorrect 5. Check fetal heart tones. Calling for help will allow all other actions to be completed more quickly. This is especially critical during an emergency situation. Next the nurse should assess the fetal heart tones to identify the effect of the bleeding on the fetus, because the fetus often shows signs of distress before the mother does. After checking the fetal heart tone the nurse should increase the IV infusion rate, which should take only seconds and can have a significant effect on circulation. Oxygen can be instituted after the IV infusion rate has been increased; this will be of benefit to both mother and fetus. Calling the primary health care provider is important, but instituting lifesaving measures takes precedence.

A client is admitted to the labor and delivery unit for labor augmentation with oxytocin (Pitocin). She is postterm at 40 weeks +3 days and is a gestational diabetic. The cervix is dilated 2 cm and 90% effaced. The health care provider performed an amniotomy to permit internal electronic fetal monitoring. The amniotic fluid is pale yellow and moderate in amount. Immediately after the amniotomy the nurse will assess the fetal heart rate for at least 1 full minute for signs of: Incorrect1 Infection 2 Uterine atony Correct3 Uterine cord prolapse 4 Maternal hypertension The umbilical cord can slip down during after the amniotomy and be compressed between the fetal presenting part and the woman's pelvis. Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or if persistent bradycardia is present after contractions. Uterine atony and maternal hypertension are not assessed with the use of electronic fetal monitoring. It is important to monitor the client for possible infection, but the risk is low immediately after amniotomy; it increases with the interval between membrane rupture and birth.