CH 15: Nursing Care During Labor & Birth Flashcards
- The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
a.
To determine the status of the membranes
b.
To determine cervical dilation and effacement
c.
To determine the best location to assess the fetal heart rate
d.
To determine whether the fetus is in the posterior position
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 pH test or fern 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.
- Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
a.
Recommend frequent position changes.
b.
Palpate her filling bladder every 15 minutes.
c.
Offer warm wet cloths to use on the patient’s face and neck.
d.
Keep the room lights lit so the patient and her coach can see everything.
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 become very hot and perspire. Cool cloths will provide greater relief. Soft indirect lighting is more soothing than irritating bright lights.
- Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
a.
Elevated pulse rate
b.
Elevated blood pressure
c.
Firm fundus at the midline
d.
Saturation of two perineal pads in 4 hours
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.
- Which intervention is an essential part of nursing care for a laboring patient?
a.
Helping the woman manage the pain
b.
Eliminating the pain associated with labor
c.
Feeling comfortable with the predictable nature of intrapartal care
d.
Sharing personal experiences regarding labor and birth to decrease her anxiety
ANS: A
Helping a patient 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; however, managing pain is a top priority.
- A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
a.
increased fetal movement.
b.
irregular contractions for 1 hour.
c.
a trickle of fluid from the vagina.
d.
thick pink or dark red vaginal mucus.
ANS: C
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. Decreased or the lack of fetal movement requires 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.
- Which patient at term should proceed to the hospital or birth center the immediately after labor begins?
a. Gravida 2, para 1, who lives 10 minutes away b.
Gravida 1, para 0, who lives 40 minutes away c.
Gravida 2, para 1, whose first labor lasted 16 hours
d.
Gravida 3, para 2, whose longest previous labor was 4 hours
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.
- A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
a.
contraction pattern, amount of discomfort, and pregnancy history.
b.
fetal heart rate, maternal vital signs, and the woman’s nearness to birth.
c.
last food intake, when labor began, and cultural practices the couple desires.
d.
identification of ruptured membranes, the woman’s gravida and para, and access to a support person.
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.
- A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be
a.
discharged home with a sedative.
b.
admitted for extended observation.
c.
admitted and prepared for a cesarean birth.
d.
discharged home to await the onset of true labor.
ANS: D
The situation describes a patient with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The patient will probably be discharged, and 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.
- The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?
a.
Inform the mother that the fetal heart rate is normal.
b.
Reassess the fetal heart rate in 5 minutes because the rate is too high.
c.
Report the fetal heart rate to the physician or nurse-midwife immediately.
d.
Suggest to the mother that she is going to have a boy because the heart rate is fast.
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.
- Which clinical finding would be an indication to the nurse that the fetus may be compromised?
a.
Active fetal movements
b.
Fetal heart rate in the 140s
c.
Contractions lasting 90 seconds
d.
Meconium-stained amniotic fluid
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.
- The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate?
a.
Every 15 minutes
b.
Every 30 minutes
c.
Every 45 minutes
d.
Every 1 hour
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.
- Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?
a.
Bloody mucous discharge increases.
b.
The vulva bulges and encircles the fetal head.
c.
The membranes rupture during a contraction.
d.
The fetal head is felt at 0 station during the vaginal examination.
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 zero station indicates engagement.
- During labor a vaginal examination should be performed only when necessary because of the risk of
a.
infection.
b.
fetal injury.
c.
discomfort.
d.
perineal trauma.
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.
- A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely
a.
a sign of abnormal labor progress.
b.
an indication that she needs analgesia.
c.
normal and related to hyperventilation.
d.
common during the transition phase of labor.
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.
- At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s trunk is pink and the hands and feet are blue. The Apgar score for this infant is
a.
7.
b.
8.
c.
9.
d.
10.
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.
- If a woman’s fundus is soft 30 minutes after birth, the nurse’s first action should be to
a.
massage the fundus.
b.
take the blood pressure.
c.
notify the physician or nurse-midwife.
d.
place the woman in Trendelenburg position.
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.
- The nurse thoroughly dries the infant immediately after birth primarily to
a.
reduce heat loss from evaporation.
b.
stimulate crying and lung expansion.
c.
increase blood supply to the hands and feet.
d.
remove maternal blood from the skin surface.
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.
- The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?
a.
Request a social service consult for psychosocial support.
b.
Observe for other signs that the mother may not be accepting of the infant.
c.
Document this evidence of normal early maternal-infant attachment behavior.
d.
Determine whether the mother is too fatigued to interact normally with her infant.
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.
- Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.
a.
Fluid volume deficit (FVD) related to fluid loss during labor and birth process
b.
Fatigue related to length of labor requiring increased energy expenditure
c.
Acute pain related to increased intensity of contractions
d.
Anxiety related to imminent birth process
ANS: D
A primipara is experiencing the birthing event for the first time and may experience anxiety due to fear of the unknown. It would be important to recognize this because the patient 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 patients includes the use of parenteral fluid therapy; the patient should be monitored for FVD and, if symptoms warrant, receive intervention. Because the patient has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara patient. Although the patient may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. The patient is entering the second stage of labor; therefore she will be allowed to push with contractions. In terms of pain management, medication will not be administered at this time because of imminent birth.
- Which of the following behaviors would be applicable to a nursing diagnosis of “risk for injury” in a patient who is in labor?
a.
Length of second-stage labor is 2 hours.
b.
Patient has received an epidural for pain control during the labor process.
c.
Patient is using breathing techniques during contractions to maximize pain relief.
d.
Patient is receiving parenteral fluids during the course of labor to maintain hydration.
ANS: B
A patient 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.