BN Ch. 66 Normal Labor, Delivery, and Postpartum Care

Question 1

A/An _____ is used to monitor the frequency of contractions.

Answer 1

tocodynamometer

Question 2

After placental delivery, administration of a __________ medication may be necessary to assist the uterus to contract and to minimize the risk of bleeding.

Answer 2

Oxytocic

Question 3

Brief increases in the fetal heart rate (FHR) of 15 beats per minute (BPM) or more are called ______.

Answer 3

Accelerations

Question 4

When the head of the fetus lies closest to the maternal pelvis, the presentation is said to be _____.

Answer 4

Cephalic

Question 5

If the uterine fundus is boggy, perform _____ massage.

Answer 5

Fundal

Question 6

What is is station 0?

Answer 6

The station at which the fetus is fully engaged is called station 0. It is seen when the widest part of the presenting
part of the fetus has lodged in the pelvic inlet and the lowest part of the fetal skull is at the level of the mother’s ischial spines.

Question 7

How is station Measured?

Answer 7

Station is measured as the relationship of the lowest bony portion of the fetal presenting part to the level of the ischial spines of the woman’s pelvic bones.

Question 8

The fetus has both legs drawn up, bent at both the hip and the knee

Answer 8

Complete

Question 9

The fetus has the hips bent, but the knees are extended

Answer 9

Frank

Question 10

Either one or both legs are extended at the hip, flexed at the knee

Answer 10

Kneeling

Question 11

Either one or both legs are extended at both the hip and knee

Answer 11

Footling

Question 12

Write the correct steps occurring during fundal massage.

1. Observe for passage of large clot; notify the healthcare practitioner if clots are numerous or frequent or if they indicate active hemorrhage.
2. Clean the client’s vulva and perineum. Apply a clean perineal pad.
3. Rotate the fundal hand gently and continue this massage until you feel that the uterus becomes a firm globe. Do not massage a contracted uterus.
4. Cup one hand around the uterine fundus. Place the other hand over the symphysis pubis to stabilize the uterus.

Answer 12

4. Cup one hand around the uterine fundus. Place the other hand over the symphysis pubis to stabilize the uterus.
5. Rotate the fundal hand gently and continue this massage until you feel that the uterus becomes a firm globe. Do not massage a contracted uterus.
6. Observe for passage of large clot; notify the healthcare practitioner if clots are numerous or frequent or if they indicate active hemorrhage.
7. Clean the client’s vulva and perineum. Apply a clean perineal pad.

Question 13

What is engorgement?

Answer 13

Engorgement is the response of the breasts to the presence of an increased volume of milk and a sudden change in hormones. It usually occurs on the third to fifth postpartum day. The breasts become tender, swollen, hot, and hard. The swelling may extend into the axilla. The breasts may look shiny and red.

Question 14

What are the two distinct cervical changes that occur during the first stage of labor?

Answer 14

Two distinct cervical changes that occur during the first stage of labor are effacement (100%) and dilation. Effacement refers to the thinning of the cervix. In dilation (10 cm), the cervical os (opening), normally held closed in a tight circle, begins to open.

Question 15

What changes occur during crowning?

Answer 15

During crowning, the rectum dilates and the perineum bulges. Also, the baby’s head begins to show for the first time.

Question 16

What are the disadvantages of delivery using epidural anesthesia?

Answer 16

Disadvantages of delivery using epidural anesthesia include the blocking of the urge to push in the second stage of labor and an increased chance of forceps delivery.

Question 17

What is colostrum?

Answer 17

Colostrum is a thin, yellowish secretion that is produced by the breasts during the last half of pregnancy and the first few days after delivery.
It provides vitamins and immune substances that protect the newborn against infection.

Question 18

A client is receiving epidural anesthesia during labor.

a. Which care would be exercised when administering epidural anesthesia during labor?

Answer 18

The client receiving epidural anesthesia during labor should be positioned on her side, with her head slightly raised. If she lies on her back, a small, firm pillow should be placed under her right hip so that the uterus tilts to the left. This measure is performed to help prevent compres- sion of the aorta and vena cava.

Question 19

Which findings would the nurse report immediately when caring for a client receiving anesthesia during labor?

Answer 19

For a client who is receiving anesthesia, the nurse should report the following findings immediately:

• Ringing in the ears
• Dizziness
• Metallic taste
• Hypotension or seizures
• Drop in fetal heart rate

Question 20

Why is general anesthesia rarely used during labor?

Answer 20

General anesthesia is rarely used during labor because the client receiving this type of anesthe- sia is asleep when the newborn arrives. Babies born this way may not breathe spontaneously and may be difficult to awaken. General anesthesia is used in emergencies only (such as an emer- gency cesarean delivery), due to the possibility of newborn central nervous system depression.

Question 21

A pregnant client has just experienced rupture of the membranes.
a. What happens when the membranes break?

Answer 21

Whenever the membranes break, either a sudden gush or a gentle trickle of fluid results; the mother should note the color of the fluid.

Question 22

Why would the nurse assess the baseline maternal temperature at the time the bag of waters ruptures?

Answer 22

When the membranes are ruptured, microorgan- isms from the vagina can travel through the cervix and enter the uterus, which poses a risk of infection to both mother and infant. For this reason, the nurse should obtain a baseline mater- nal temperature at the time the bag of waters ruptures and continue to assess the client’s temperature every 2 hours until delivery. If the client’s temperature begins to increase, the practi- tioner will usually initiate measures to prevent infection of the fetus.

Question 23

Which nursing care would the nurse focus on during the first stage of labor?

a. Assessment of client’s vital signs
b. Assessment of the placenta
c. Administration of an oxytocic medication
d. Assessment of the newborn

Answer 23

a. Assessment of client’s vital signs

• Rationale: First-stage nursing care focuses on assessment of the client’s vital signs, contractions, and cervical change, as well as assessment of the fetal well-being. These findings help the birth attendant to determine the fetal condition and the woman’s progress. Assessment of the newborn is done in the second stage. Assessment of the placenta and administration of an oxytocic medication is done in the third stage.

Question 24

A pregnant client asks the nurse how they can identify whether they are in labor. Which signs are most likely to indicate that labor is approaching? Select all that apply.

a. Strong and regular contractions
b. Greater difficulty in breathing
c. Decrease in pedal edema
d. Increase in urinary frequency
e. Cervical effacement

Answer 24

a. Strong and regular contractions
d. Increase in urinary frequency
e. Cervical effacement

*Rationale: Regular contractions that may become stronger show cervical effacement and dilation, urinary frequency, and increased edema of the legs are the signs that indicate labor is approaching. Difficulty in breathing and decrease in pedal edema are not signs of approaching labor.

Question 25

A pregnant client has been told by the nurse practitioner that they are in false labor. Which statement is true regarding false labor?

a. Rhythmic uterine contractions that grow stronger
b. Increase in duration (length) of each contraction
c. Irregular pattern of uterine contractions
d. Lower-back pain that moves gradually around to the abdomen

Answer 25

c. Irregular pattern of uterine contractions

• Rationale: Characteristics of false labor include contractions felt low in the abdomen; irregular contractions, the intensity of which does not grow with time; no cervical changes; and no bloody show. Rhythmic uterine contractions that grow stronger and increase in duration and lower-back pain that moves gradually around to the abdomen are characteristics of true labor.

Question 26

A nurse is assessing a client in the postpartum period. Which is a normal assessment in the postpartum period?

a. Involution of the uterus
b. Pain behind the knee on flexion of the feet
c. Voiding of small amounts of urine
d. Redness, pain, and swelling along a vein

Answer 26

a. Involution of the uterus

• Rationale: Involution is a normal process in which the client’s reproductive organs begin to return to their normal pre-pregnant size. Pain behind the knee on flexion of the feet indicates a positive Homans sign and suggests thrombophle- bitis. Redness, pain, and swelling along the path of a vein may indicate superficial thrombophlebitis. Bruising and swelling of the urethra and general loss of muscle tone could cause voiding of small amounts of urine.

Question 27

A nurse is assessing a client to whom oxytocin is being given for labor augmentation. In which situation would the nurse immediately report the observation of contractions?

a. Contractions are rhythmic and becoming stronger
b. Contractions come more often than every 2 min
c. Uterine contractions are causing pain
d. Each contraction lasts less than 90 s

Answer 27

b. Contractions come more often than every 2 min

*Rationale: The nurse reports immediately if contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer. In these cases, there is not enough relaxation time for the fetus to be well oxygenated. This event is rare during normal labor but must be carefully watched for when oxytocin is used for labor augmentation or induction. Rhythmic contractions becoming stronger or contractions causing pain are normal and not a cause of concern. Contractions lasting less than 90 seconds are normal.

Question 28

Which characteristic of amniotic fluid is abnormal?

a. Clear and colorless
b. Slightly salty odor
c. Yellow, green, or cloudy
d. pH of 7.0-7.5

Answer 28

c. Yellow, green, or cloudy

*Rationale: Yellow or green fluid may indicate that the fetus has passed meconium, or stool, while still in utero and is therefore abnormal. Normal amniotic fluid is clear and colorless and has a slightly salty odor with a pH of 7.0 to 7.5 (neutral to slightly alkaline).

Question 29

A client who is breastfeeding their baby complains of painful and swollen breasts. Which measure helps to relieve the nursing client’s breast engorgement?

a. Using medications (usually acetaminophen) as prescribed
b. Placing cold packs on their breasts three to four times a day
c. Avoiding manual expression or pumping of the breasts
d. Wearing a supportive

Answer 29

d. Wearing a supportive

• Rationale: Wearing a supportive bra, frequent breastfeeding, and applying warm packs to the breast for 15 minutes before nursing or standing in the shower with warm water spraying on the breast for 15 minutes before nursing are measures that help to relieve the nursing mother’s engorge- ment. Using medications, placing cold packs on her breasts, and avoiding manual expression or pumping are measures that can help to relieve breast engorgement in the non-nursing mother, not the nursing mother.

Question 30

A nurse is assessing the progress of labor of a client. Which station indicates that the fetus is “floating”?

a. Station +5
b. Station 0
c. Station -5
d. Station -1

Answer 30

c. Station -5

*Rationale: A station of 5 is considered “floating.” The station at which the fetus is fully engaged is called station 0; that is, the widest part of the presenting part of the fetus has lodged in the pel- vic inlet, and the lowest part of the fetal skull is at the level of the mother’s ischial spines. A station of 1 5 means that the fetal head is at the vaginal opening. Station 21 is 1 cm above the ischial spines.

Question 31

A nurse is assessing the lochia of a postpartum client. Which characteristics of lochia are abnormal? Select all that apply.

a. Large clots are present in lochia.
b. Clear serous discharge occurs for the first 2 days.
c. Lochia does not change color and characteristics.
d. Lochia has a fleshy or metallic odor.
e. Lochia serosa has a slightly earthy odor.

Answer 31

a. Large clots are present in lochia.
b. Clear serous discharge occurs for the first 2 days.
c. Lochia does not change color and characteristics.

• Rationale: Large clots, clear serous discharge
  that occurs for the first 2 days and lochia that does not change color or characteristics are all abnormal findings of lochia. For the first 2 days, lochia is mostly red and bloody, not clear and serous. Lochia should have a fleshy or metallic but never a foul odor. Lochia serosa has a slightly earthy odor, and lochia alba also has an earthy smell.

Question 32

Given below are the steps for application of an external monitor in random order.Arrange the steps in the correct order.

a. Attach straps to the Doppler instrument and secure. Place tocodynamometer on the abdomen between umbilicus and top of fundus.
b. Review fetal heart rate and uterine assessment data with client and family. Use thorough descriptions of data.
c. Apply conductive jelly to Doppler instrument and place on client’s abdomen until a strong fetal heart rate is heard and a
consistent signal is obtained.
d. Elevate head of bed 15°-30°, or place the client in lateral position. Perform Leopold maneuvers and place two straps under the client.

Answer 32

d. Elevate head of bed 15°-30°, or place the client in lateral position. Perform Leopold maneuvers and place two straps under the client.
c. Apply conductive jelly to Doppler instrument and place on client’s abdomen until a strong fetal heart rate is heard and a
consistent signal is obtained.
a. Attach straps to the Doppler instrument and secure. Place tocodynamometer on the abdomen between umbilicus and top of fundus.
b. Review fetal heart rate and uterine assessment data with client and family. Use thorough descriptions of data.

*Rationale: Elevate the head of bed about 15 to 30 degrees, or place the client in lateral position, because elevation and uterine displacement decrease compression of the aorta and vena cava. Perform Leopold maneuvers and place two straps under the client. This locates fetal position and best placement of the Doppler instrument. Apply conductive jelly to the Doppler. This helps to locate the area of maximum fetal heart rate (FHR) signal. Place the Doppler on the client’s abdomen until a strong FHR is heard and a consistent signal is obtained. Attach straps to the Doppler and secure. Place the tocodynamometer on the abdomen between the umbilicus and top of fundus, because this is the contractile portion of the uterus. Care must be taken to avoid placing the tocodynamometer too high on the fundus; otherwise, respirations will be recorded on the monitor. Review FHR and uterine assessment data with client and family. Use thorough descriptions of data. This review promotes understanding of what the client and her family will be observing on the monitor.