question

Infection is identified as a nursing problem for a patient with a cesarean section. Which nursing interventions should the nurse expect to implement? Select all that apply. (pg 831)

answer

-Increase fluid intake -Use good aseptic technique -Monitor white blood cell count

question

A nurse is caring for a patient in active labor. On assessment of the patient, meconium-stained fluid is present. What can the nurse conclude about the data received from the assessment? (pg 819)

answer

The fetus is experiencing distress

question

The registered nurse finds the occurrence of fetal bradycardia in a patient and performs scalp stimulation after notifying the primary health care provider. What is the rationale for this intervention? (pg 815)

answer

To assess the ability of the fetus to compensate the physiological stress

question

A student nurse is being mentored in the delivery room by an experienced nurse. Which action if performed by the student requires immediate correction? (pg 820)

answer

The student suctions the back of the baby's throat

question

Which characteristics are indications of true labor? Select all that apply. (pg 799-800)

answer

-Contractions follow a regular pattern. -The cervix softens, effaces, and dilates -Contractions get stronger with ambulation

question

A nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position? (pg 806)

answer

Left lateral side-lying

question

A pregnant mother arrives in the emergency center with a fetal leg and an umbilical cord descending from the vagina. What immediate intervention should the nurse take to prevent potential damage to the fetus? (pg 803-804)

answer

Assist the mother to a knee-chest position

question

A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic? (pg 799)

answer

Deep Blue

question

A pregnant patient calls the clinic and explains to the nurse that she is experiencing pain with no distinctive pattern; the pain varies in length and intensity, and it stops when she gets up and moves around. What can the nurse infer about the patient's labor? (pg 800)

answer

The pt is having false labor

question

In assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring? (pg 815)

answer

Late decelerations

question

Which signs indicate false labor? Select all that apply. (pg 799-800)

answer

-Contractions stop with ambulation -Contractions stop with position change

question

A newly delivered patient is lying in bed bonding with her infant. When the nurse assesses the patient, the uterine fundus lacks muscle tone and firmness. What immediate action should the nurse take? (pg 805)

answer

Gently massage the fundus until firm

question

A patient with preeclampsia is given magnesium sulfate. The nurse suspects toxicity. What action should the nurse take to determine if the patient is experiencing toxicity from the medication? (pg 813)

answer

Using a reflex hammer to assess deep tendon reflexes

question

A pregnant patient is undergoing a vaginal delivery with the help of forceps. What could be the factor for a forceps delivery? (pg 801)

answer

Oval, wider brim of the pelvis

question

A patient has been admitted to a labor delivery and recovery (LDR) unit. The nurse is assessing the patient to determine if the membrane has ruptured. What intervention would the nurse carry out to determine the status of the membrane? (pg 799)

answer

Test the fluid with nitrazine paper

question

A patient with a previous history of rickets is seeking preconception care. Which diagnostic procedure does the nurse expect the primary health care provider to suggest to the patient? (pg 800)

answer

Pelvimetry

question

The nurse is caring for a neonate who is suffering from irregular breathing due to improper expansion of lungs. What is the reason for the impaired expansion of lungs? (pg 820)

answer

The neonate has decreased production of surfactants

question

A primary health care provider is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery? (pg 802)

answer

LOA

question

A patient has been in labor for 6 hours and is anxious and restless. The nurse encourages the patient to ambulate in the hallways. What effect should the nurse expect ambulation to have on the patient? (pg 821)

answer

Strengthen the effectiveness of labor

question

A laboring patient has just had membranes ruptured by the primary health care provider. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate? (pg 819)

answer

Passage of meconium stool by the fetus

question

While reviewing the amniotic fluid assessment report in a pregnant patient who is in the 36th week of gestation, the nurse finds the patient has 400 mL of yellow-stained amniotic fluid. What should the nurse infer from this finding? (pg 819)

answer

The fetus may have incompletely developed kidney.

question

While collecting a pregnant patient's data, the nurse finds that the amniotic fluid is thick and cloudy. Which condition is responsible for increase in thickness of amniotic fluid? (pg 819)

answer

Excess meconium

question

An expectant mother is experiencing labor. Contractions are occurring 2 to 3 minutes apart and have a duration of 90 seconds, and lower back pain is evident. The nurse can best interpret the data as reflecting which stage of labor? (pg 808-809)

answer

Transitional phase

question

A hospitalized pregnant woman has a prescription for magnesium sulfate. What assessment finding would the nurse report to the primary health care provider immediately? (pg 813)

answer

Urinary output of 15 mL/hr

question

During the delivery of a patient's baby, the primary health care provider finds that the umbilical cord is prolapsed. Which position should the nurse suggest the patient to assume? (pg 803-804)

answer

Modified Sims position

question

What is the term for shortening and thinning of the cervix during the first stage of labor? (pg 799)

answer

Effacement

question

A patient from a different country is admitted to a labor and delivery unit and is near delivery. Neither the patient nor the family understands English. There is no staff that can interpret the patient's language. Consent forms need to be signed and the risks of any procedures explained. What is the best action for the nurse to take? (pg 826)

answer

Call a translator service and have them translate over the phone

question

A patient in labor has been pushing in the squatting position for several hours. Just as the nurse notices a decrease in cardiac output, the patient insists that she has to lie flat. What action should the nurse take next? (pg 806)

answer

Place the patient in the lateral position

question

The nurse is evaluating the physical conditions of a neonate using the Apgar scoring tool. The nurse enters the score of respiratory rate as 2 points. What does the score signify? (pg 819)

answer

Good crying

question

The nurse is caring for a pregnant woman who is in labor. What outcomes indicate that the nursing interventions are effective? Select all that apply. (pg 827)

answer

-The patient relaxes between the contractions. -The patient participates in anxiety-reducing activities. -The patient performs breathing techniques effectively. -The patient uses relaxation techniques to cope with the labor pain

question

An expectant mother in labor has become anxious and apprehensive. Which drug(s) if administered by the nurse could decrease or eliminate anxiety and apprehension in the patient? Select all that apply. (pg 824)

answer

-Diazepam (Valium) -Hydroxyzine (Vistaril)

question

When the delivery of the placenta is complete, which stage of labor is complete? (pg 812)

answer

Third stage

question

A pregnant patient has a positive nitrazine paper test and has been prescribed oxytocin (Pitocin) by the primary health care provider. What could be the reason for prescribing this drug to the patient? (pg 830)

answer

Oxytocin (Pitocin) is given to induce uterine contractions during labor.

question

The nurse is monitoring the fetal heart rate and finds it to be 185 beats per minute. What is the best nursing intervention? (pg 815)

answer

Inform the primary health care provider

question

A seasoned nurse is caring for a young mother in labor. The husband calls the nurse outside the room and explains that he feels guilty for not being able to help his wife. What would be the best response? (pg 822)

answer

\"Just provide support, be caring, and make her comfortable.\"

question

The nurse administers ritodrine hydrochloride (Yutopar) to a pregnant patient to prevent preterm labor. What should the nurse monitor in the patient? (pg 813)

answer

Fetal tachycardia

question

The nurse is caring for a patient who is prescribed misoprostol (prostaglandin E) for relief from normal labor pain. Which measure should be taken by the nurse during the administration? (pg 812)

answer

Prevent contact of the drug with the patient's skin.

question

The practical nurse is assisting the primary health care provider for the nitrazine test. The primary health care provider dips a cotton-tipped sterile applicator into the vagina of a 7-month pregnant patient who experiences labor pain. On removing the applicator, the nurse finds the color of fluid when applied to nitrazine paper is blue-gray. What does the color of the fluid signify? Select all that apply. (pg 799)

answer

-The fluid is alkaline in nature. -The membranes are ruptured

question

A pregnant patient is undergoing external monitoring with an ultrasound transducer. The nurse finds that the patient has reddened skin areas due to the belt. Which intervention should the nurse follow? (pg 818)

answer

Massage the skin gently and reposition the belt every two hours

question

The nurse is caring for a pregnant patient who is in labor. Which nursing interventions should be performed by the nurse to prepare the patient for the childbirth? Select all that apply. (pg 821)

answer

-Encourage ambulation in the patient. -Provide the patient with a warm shower. -Encourage the patient to lie in a comfortable position. -Encourage the patient to have small amounts of fluids

question

A nurse has just assisted with the delivery of a full-term infant. What immediate intervention should the nurse carry out to prevent hypothermia? (pg 820)

answer

Dry the infant with a blanket

question

A pregnant patient with a sudden outflow of fluid from the vagina has been instructed to undergo the nitrazine test. In which order should the nurse perform the nitrazine test? (pg 798-799)

answer

-Wash hands and put on gloves. -Place nitrazine paper on the cervical opening. -Read the results of the test. -Provide pericare as needed. -Remove gloves and wash hands. -Document the results of the test

question

A Native American mother has just delivered a healthy newborn infant. The mother is requesting to take the placenta home with her. What is the best response the nurse can give? (pg 826)

answer

\"I will start the process for you to take the placenta.\"

question

Which statement if found on the care plan indicates the patient in labor is maintaining a mild to moderate level of anxiety? (pg 828)

answer

Patient is dozing between contractions.

question

The nurse is caring for a pregnant patient who is prescribed naloxone hydrochloride (Narcan). The nurse finds that the patient is also addicted to cocaine. What adverse effect would the nurse expect if the patient is administered naloxone hydrochloride (Narcan)? (pg 814)

answer

Seizures

question

A neonate, after one minute following birth, has a good cry, a heart rate of 110 beats per minute, a pink body with blue extremities, sneezes on stimulation, and active motion. What is the Apgar score for this neonate? Record your answer using a whole number. (pg 819)

answer

9

question

ROM

answer

Rupture of Membranes

question

When doing a nitrazine test do you was the periarea before or after?

answer

After the test, do not wash before the test

question

How do you tell if the nitrazine test is positive for amniotic fluid?

answer

The test paper turns blue

question

What can cause false test results on a nitrazine test?

answer

-Bloody show -Insufficient amniotic fluid -Semen

question

How long should delivery occur after membranes rupture?

answer

Within 24 hrs

question

Braxton hicks contractions

answer

irregular tightening of the pregnant uterus that begins in the first trimester and increases in frequency, duration, and intensity as pregnancy progresses

question

Braxton hicks remain irregular and

answer

do not dilate the cervix

question

Spontaneous ROM

answer

natural rupture of the membranes, happens on its own

question

Artificial ROM

answer

does not happen on its own, physician or midwife ruptures the membranes with a special tool -Amniotomy(artificial rupture of the fetal membrane)

question

Signs of True Labor

answer

_Contractions follow a reg pattern -Contractions come closer together, are stronger, and tend to last longer -Contractions get stronger with ambulation -Contractions seem to start in the lower back and then travel to the lower abdomen -Contractions are usually not stopped with controlled breathing, sedation, or other relaxation interventions -Cervix softens, effaces, and dilates -Fetus continues descent into the pelvis

question

Signs of False Labor

answer

-Contractions rarely follow a pattern -Contractions vary in length and intensity -Contractions frequently stop with ambulation or position change -Contractions may be felt in the back but are most often noticed in the fundus -Contractions eventually stop with relaxation interventions -Cervix may soften, but with little or no change in effacement or dilation -No significant change in the fetal position occurs

question

True pelvis

answer

Divided into 3 segments -inlet -cavity or midpelvis -outlet Fetal head must be able to pass through the true pelvis for vaginal delivery

question

Eval of the size of the true pelvis

answer

-Palpation -Pelvimetry -Ultrasonography

question

Whats the only way to know if the pts pelvis is adequate for vaginal birth?

answer

Trial vaginal birth

question

Uterine contractions

answer

during labor, the muscles in the upper uterine segment, the fundus, thicken and contract at intervals

question

Molding

answer

-bones of the fetal skull are not rigidly fused, which allows the bony plates to move and overlap as they progress through the maternal pelvis. -reshaping of the skull bones in response to pressure against the maternal pelvis

question

5 P's

answer

-Passageway: pelvis and soft tissue -Passenger: fetus and placenta -Powers: contractions -Position of mother: standing, walking, side lying, squatting, hands and knees -Psyche: psychological

question

Fontanels

answer

-Anterior fontanel formed by 4 bones & thus tends to be larger and diamond shaped -Posterior fontanel formed by three bones and is smaller and triangular (with palpation of the fontanelles and sutures through the dilated cervix, the PCP can determine the presentation of the fetus during labor.)

question

Stages of Labor

answer

Three stages -1st: Dilation -2nd: Delivery of the fetus -3rd: Delivery of the placenta -4th: Stabilization

question

First stage of labor

answer

-Latent phase: *0-3cm *irregular, mild to moderate contractions *Frequency 5-30 min *duration 30-45 seconds *Maternal Characteristics (some effacement and dilation, talkative and eager) -Active phase: *4-7cm *more regular, moderate to strong contractions *frequency 3-5 min *duration 40-70 seconds *maternal characteristics (rapid dilation and effacement, some fetal descent, feelings of helplessness, anxiety and restlessness increase as contractions become stronger) -Transition phase: *8-10cm *strong to very strong contractions *frequency 2-3 min *duration 45-90 seconds *maternal characteristics (tired, restlessness, and irritable, feeling out of control, client often states, \"cannot continue\", can have nausea and vomiting, urge to push, increased rectal pressure and feelings of needing to have a bowel movement, increased bloody show, most difficult part of labor)

question

Second stage of labor

answer

-Full dilation to birth -progresses to intense contractions every 1-2 min -maternal characteristics: pushing results in birth of fetus

question

Third stage of labor

answer

-Delivery of neonate to delivery of placenta -Maternal characteristics: Placental seperation and expulsion, schultze presentation:shiny fetal surface of placenta emerges first, duncan presentation: dull maternal surface of placenta emerges first

question

Fourth stage of labor

answer

-Delivery of placenta to maternal stabilization of V/S -Maternal characteristics: achievement of V/S homeostasis, lochia scant to moderate rubra

question

Lochia

answer

a vaginal discharge occurring after childbirth. Lochia discharge should be checked every 15 minutes for the first hour after delivery, once every hour for the first 8 hours, and then every 8 hours.

question

Rubra

answer

red

question

Dilation

answer

opening of the cervix measured in cm

question

Effacement

answer

thinning of the cervix measured in percentage

question

Descent

answer

is the downward progress of the presenting part

question

The amount of progress is measured by comparing the lowest point of the presenting part with the ischial spines, this is referred to as the

answer

Station

question

The station is measured in cm above or below the spines

answer

0: equal with the ischial spine -2: 2cm above the spines +2: 2cm below the ischial spines

question

What are the possible complications of an episiotomy?

answer

-Infection -Blood loss -Pain -Painful sexual intercourse

question

Episiotomy-2 types

answer

(surgical incision of the perineum performed at the end of the 2nd stage of labor) -Midline/median: most common, separates the tissues of the perineum at an anatomic junction. *advantages- ease in completing the procedure, speed of healing, comfort over the mediolateral. *greater risk for further extension and tearing -Mediolateral: if the perineum is too small or the fetus is anticipated to be large this type is done, cutting the muscle, more uncomfortable and only done when necessary

question

EFM

answer

-Electronic Fetal Monitoring, can be internal or external -Fetal monitoring in relation to the contractions

question

External (indirect) fetal monitoring

answer

-uses external transducers on the maternal abdominal wall to assess FHR (fetal heart rate) and uterine activity -does not require ROM or cervical dilation -Ultrasound transducer uses high-frequency sound waves to reflect movement of the fetal heart ventricles -Maternal position can affect accuracy of reading

question

Internal fetal monitoring

answer

-Uses a spiral electrode applied to presenting part to monitor the FHR -membranes must be ruptured and the cervix dilated to 2-3cm -accurate no matter the maternal position

question

Decrease in FHR occurs in response to the contractions and is called

answer

-Decelerations (can be early, late, or variable)

question

What is the normal baseline heart rate for the fetus?

answer

120-160 bpm

question

Tachycardia and interventions

answer

-moderate increase to 160-180bpm -marked increase > than 180bpm (significant if variability is absent and late or variable decels are present *interventions: depend on the cause -reduce maternal fever with antipyretics as ordered and cooling measures -O2 @ 8-10 L/min may be of some value -carry out HCP orders to alleviate cause

question

Bradycardia and interventions

answer

-moderate decrease to 100-120bpm -marked decrease <100bpm (significant if variability is decreased or absent or if late or variable decels are present) *interventions: depend on the cause -not warranted in fetus with heart block dx with electrocardiogram -O2 @ 8-10L/min via face mask may be of some value -carry out HCP orders to alleviate cause -Scalp stimulation may be performed to determine whether the fetus is able to compensate phsyiologically for stress

question

Variability

answer

-measures the normal fluctuation of the FHR from the baseline -absent or minimal variability possibly indicative of fetal distress -variability classified as long term (LTV) or short term (STV)

question

Decelerations

answer

Periodic decreases in the FHR in responce to contractions; classified as early, late, or variable

question

Early Decel

answer

caused by pressure on fetal skull; onset, shape, and recovery correspond to contractions

question

Late decel

answer

caused by decreased oxygena dn blood flor to the fetus through the placenta; noted at or after the peak of the contraction; may indicate fetal distress, particularly if assoc with changes in baseline FHR and absence of variability

question

Variable decel

answer

caused by compression on the umbilical cord; occur randomly and onset may be sudden; FHR decreases below normal range

question

Intervention for decels

answer

notify the primary caregiver immediately and intiate appropriate treatment when pt has a prolonged decel

question

What is the first thing you do when the head of the baby comes out?

answer

Maintain airway by suctioning the mouth first and then nose, suctioning the nose first will cause the baby to aspirate on mucous in the mouth

question

Priorities during immediate newborn delivery

answer

-Suction airway -Warmth; immediately dry the baby to prevent hypothermia then place the infant in contact with the mother's skin or in the warming unit -If no complications occur keep infant in mothers view; apply ID bracelets on mother and baby before they leave the delivery room

question

The infant's physical condition is evaluated at birth, most facilities us an evaluation guide called

answer

Apgar score

question

Apgar

answer

-Scoring done at 1 and 5 minutes of age -Score can range from 0-10 -8-10 being optimal -criteria used include heart rate, resp effort, muscle tone, reflex irritability, and skin color

question

Apgar scoring

answer

0: *heart rate- absent, *resp effort- absent, *muscle tone- flaccid, limp, *reflex irritability- no response, *skin color- pale blue 1: *heart rate- slow, 100bpm (between 120-160), *resp effort- good crying (screaming), *muscle tone- active motion, *reflex irritability- vigorous cry, cough, sneeze (does baby gag when suctioned), *skin color- completely pink

question

Maternal assessment after delivery

answer

-monitored 1-4 hrs depending on how the birthing went -assess vital signs (every 15 min first hr, every 30 min 2nd hr, every hr 3rd hr, every 4 hrs) -assess uterine tone -assess vaginal drainage -assess perineal tissue

question

4 pelvic types

answer

Gynecoid Android Anthropoid Platypelloid

question

Gynecoid (most common and favorable)

answer

-50% of women have this type of pelvis -Transversely rounded -Moderate depth -Straight side walls -Blunt, somewhat widely separated ischial spines -Wide subpubic arch -Deep curved sacrum -Vaginal is usual mode of delivery (spontaneous, occiput anterior position)

question

Android- 23%

answer

-Heart shaped, angulated -Deep depth -Convergent side walls -prominent, narrow interspinous diameter ischial spines -slightly curved, terminal portion often breaked sacrum -narrow subpubic arch -Cesarean or vagainal (difficult with forceps) mode of delivery

question

Anthropoid- 24%

answer

-Oval, wider anteroposteriorly brim -deep depth -straight sidewalls -prominent, often nerrow interspinous diameter ischial spines -slightly curved sacrum -narrow subpubic arch -vaginal (with forceps or spontaneous, occiput posterior or occiput anterior position) mode of delivery

question

Platypelloid- 3%

answer

-flattened anteroposteriorly wide transversely brim -shallow depth -straight sidewalls -blunted, widely seperated ischial spines -slightly curved sacrum -wide subpubic arch -vaginal (spontaneous) mode of delivery

question

Fetal position

answer

position is the relationship of the presenting fetal part to a quadrant of the maternal pelvis, can be determined with abdominal inspection and palpation (Leopold's maneuvers), vaginal or rectal exam, auscultation of fetal heart tones, or ultrasound or xray

question

Most common and most favorable fetal position

answer

LOA- Left occiptoanterior (baby is facing down and to the left)

question

2nd most common and favorable fetal position

answer

ROA- right occipitoanterior (baby is facing down and to the right)

question

A longitudinal lie, well-flexed attitude, and vertex presentation are

answer

ideal

question

Why is the occiput anterior position more preferred?

answer

the fetal skull provides a smooth, round surface, which is most effective in effacement and dilating the cervix, the smooth regular shape also fills the cervix and prevents the umbilical cord from prolapsing or coming before the fetus

question

Why is cord prolapse dangerous

answer

pressure on the vessels in the cord can restrict blood flow to the fetus

question

fetal hypoxia from prolonged cord compression (occlusion of blood flow to and from the fetus for more than 5 minutes) usually results in what

answer

CNS damage or death

question

How can the examiner relieve pressure off the cord?

answer

by taking a sterile gloved hand into the vagina and holding the presenting part off the umbilical cord

question

What positions is the woman assisted to in the case of prolapsed cord?

answer

-Modified sims -Trendelenburg -Knee-chest so that gravity keeps the pressure of the presenting part off of the cord

question

If cervix is fully dilated and fetus in cephalic position forceps assisted or vacuum assisted delivery can be performed; if not what type of birth is likely?

answer

Cesarean

question

Nonreassuring fetal status, inadequate uterine relaxation, and bleeding can also occur as a result of a

answer

prolapsed umbilical cord

question

Placental separation is indicated by

answer

-firmly contracting fundus -change in the uterus from discoid (disk-like) to globular ovoid (egg-shaped) as the placenta moves to the lower segment -gush of dark bloood from the intoitus (the entrance into the vagina) -apparent lengthening of the umbilical cord as the placenta gets closer to the introitus -vaginal fullness (placenta) noted on vaginal or rectal exam or fetal membranes seen at the introitus

question

Delivery of the placenta completes what stage of labor?

answer

Third stage (15-30 min)

question

Primary powers

answer

-Involuntary uterine contractions -signal the beginning of labor -responsible for effacement and dilation of the cervix and descent of the fetus

question

Secondary powers

answer

-Voluntary bearing down (contracts the diaphragm and abdominal muscles and pushes) -augment the force of the involuntary contractions -result in increases intraabdominal pressure that compresses the uterus on all sides and increases the expulsive forces -no effect on cervical dilation, but are important in expelling the infant from the uterus and vagina after the cervix is fully dilated

question

Stadol

answer

-short 1/2 life -synthetic, centrally acting analgesic; provides relief of moderate to severe pain during labor -side effect: drowsiness, sedation, headache, vertigo, dizziness, weakness, confusion, insomnia, nervousness, resp depression, change in b/p, palpitations, bradycardia, nausea, clammy skin, tingling, flushing and warmth, diaphoresis, skin rash, pruritus, increased urinary output -neonatal side effects: resp depression, disorganized infant behavior, tendency for frequent crying -Nursing implications: monitor for resp depression, do not give if resp rate is <15 per min, monitor V/S, observe neonate for resp depression, observe safety precautions because of sedation and dizziness

question

Demerol

answer

-synthetic morphine like compound that produces comparable analgesic effects and provides relief of moderate to severe pain -side effects: pruritus, dizziness, sedation, weakness, euphoria, resp depression, hypotension, papitations, bradycardia or tachycardia, dry mouth, nausea, constipation, oliguria, urinary retention -neonate side effects: resp depression -nursing implications:

OB ch 26 Labor and Delivery

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