ch 14 nursing management during labor and brith Flashcards
a woman in labor received an opioid for pain relief and develops respiratory depression, the nurse would expect what to be administered?
naloxone
a client’s membranes spontaneously ruptured, as evidenced by a gust of clear fluid with a contraction. what would the nurse do next?
check fetal heart rate
a woman is admitted to the labor and birthing suite. vaginal examination reveals that the presenting part is approx 2 cm above the ischial spines. the nurse documents this finding as:
-2 station
a client states i think my water broke and i feel a gush of fluid between my legs. the nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:
blue
a woman in labor is to receive continuous internal electronic fetal monitoring. the nurse prepares the client for this monitoring based on the understanding that which criterion must be present?
cervical dilation of 2 cm or more
a woman in labor has chosen to use hydrotherapy as a method of pain relief. which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?
the temperature of the water should be at least 105 F (40.5 C)
a woman in labor received an opioid close to the time of birth. the nurse would assess the newborn for which effect?
respiratory depression
when applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the clients body?
between the umbilicus and symphysis pubis
after describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the needs for additional teaching?
unfortunately, i’m going to have to stare quite still in bed while it is in place
which action is a priority when caring for a woman during the fourth stage of labor?
assessing the uterine fundus
when palpating the fundus during a contraction, the nurse notes that it feels like a chin. the nurse interprets this finding as indicating which type of contraction?
moderate
when planning a care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?
every 30-60 minutes
a nurse palpates a woman’s fundus to determine contraction intensity. what would be the most appropriate for the nurse to use for palpation
finger pads
a woman’s amniotic fluid is noted to be cloudy. the nurse interprets this finding as:
a possible infection
a nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. after teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid base status? select all that apply
-sinusoidal pattern
-recurrent variable deceleration
-fetal bradycardia
a nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a u shape. the nurse interprets these changes as reflecting which type of deceleration?
variable deceleration
a nurse is explaining the use of effleurage as pain relief during labor. which statement would the nurse most likely use when explaining this measure?
the technique involves light stroking of the abdomen with breathing
a nurse is reading a journal article about the various mediations used for pain relief during labor. which drug would the nurse note as producing amnesia but no analgesia?
midazolam
a nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. which statement by the group indicates that the teaching was successful?
we can get up and walk around after receiving combined spinal-epidural analgesia
a nurse is completing the assessment of a woman admitted to the labor and birth suite. which information would the nurse expect to include as part of the physical assessment select all that apply.
-fundal height measurement
-membrane status
-contraction pattern
a pregnant woman admitted to the birth and labor suite undergoes rapid HIV testing and is found to be positive. which actions would the nurse expect to include when developing a plan of care? select all that apply.
-avoiding scalp electrodes for fetal monitoring
-refraining from obtaining fetal scalp blood for pH testing
-administering antiretroviral therapy at the onset of labor
which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman in the first stage of labor. select all that apply.
-walking with partner support
-straddling with forward leaning over a chair
-rocking back and forth with foot on chair
which suggestion by the nurse about pushing would be most appropriate for the second stage of labor?
choose whatever method you feel most comfortable with for pushing
a nurse is assessing a woman after birth and notes a second degree laceration. the nurse interprets this as indicating that the tear extends through which area?
muscles of perineal body
