Ch. 16 Flashcards
Nursing Care of Family
The nurse recognizes that a woman is in true labor when she states
The contractions in my uterus are getting stronger and closer together
The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the womans understanding of the instructions when she states, True labor contractions will
Continue and get stronger even if I relax and take a shower.
When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should
Ask the woman to describe why she believes she is in labor
What is an expected characteristic of amniotic fluid
Pale, straw color with small white particles
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the womans risk for _________________________ has increased
Intrauterine infection
Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions
Evaluate the intensity by pressing the fingertips into the uterine fundus
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be
Dilation of the cervix
The nurse who performs vaginal examinations to assess a womans progress in labor should
Discuss the findings with the woman and her partner.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurses initial response would be to
Assess the fetal heart rate and pattern
A nulliparous woman who has just begun the second stage of her labor would most likely
Feel tired yet relieved that the worst is over
The nurse knows that the second stage of labor, the descent phase, has begun when
The woman experiences a strong urge to bear down
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:
Encouraging the woman to try various upright positions, including squatting and standing
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as
First stage, active phase
The most critical nursing action in caring for the newborn immediately after birth is
Keeping the newborns airway clear
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the womans fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that
The placenta has separated
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to
Stimulate uterine contraction
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to
Stimulate the uterus to contract
A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that true labor contractions
Increase with activity such as ambulation
A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurses best response is
Its normal to be anxious about labor. Lets discuss what makes you afraid
For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of
Formulation of the womans plan of care for labor.
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate
Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care?
The patients weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth
Leopold maneuvers would be an inappropriate method of assessment to determine
Gender of the fetus.
In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except
Appearance (shape and height)
Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is
Heard lower and closer to the midline of the mothers abdomen as the fetus descends and rotates internally
Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?
When accelerations of the fetal heart rate (FHR) are noted
With regard to a womans intake and output during labor, nurses should be aware that:
The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia
If a woman complains of back labor pain, the nurse could best suggest that she
Lean over a birth ball with her knees on the floor
Which description of the phases of the second stage of labor is accurate
Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied
Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when
The nurse is unable to feel the cervix during a vaginal examination
A means of controlling the birth of the fetal head with a vertex presentation is
The Ritgen maneuver
Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)
A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
Concerning the third stage of labor, nurses should be aware that
An expectant or active approach to managing this stage of labor reduces the risk of complications
For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?
Limiting the number of procedures that invade her body
As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance?
Mexico
A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?
Active phase
The primary difference between the labor of a nullipara and that of a multipara is the
Total duration of labor
What is an essential part of nursing care for the laboring woman?
Helping the woman manage the pain
A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are
Fetal heart rate, maternal vital signs, and the womans nearness to birth.
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 woman to be:
Discharged home to await the onset of true labor.
A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to
Ask her to turn to one side.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
The vulva bulges and encircles the fetal head
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 infants trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant?
9
The nurse thoroughly dries the infant immediately after birth primarily to
Reduce heat loss from evaporation
Women who have participated in childbirth education classes often bring a birth bag or Lamaze bag with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including
Rolling pin
Tennis balls.
Pillow
Stuffed animal or photo
VE - Step 1
Use sterile gloves and soluble gel for lubrication
VE - Step 2
Position the woman to prevent supine hypotension
VE- Step 3
Cleanse the perineum and vulva if necessary.
VE- Step 4
After obtaining permission, gently insert the index and middle fingers into the vagina
VE- Step 5
Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid
VE- Step 6
Explain findings to the patient
VE - Step 7
Document findings and report to the provider
Instruct the patient and partner in the use of specific relaxation techniques
Acute pain related to contractions
Continue to provide comfort measures and minimize distractions
Risk for impaired individual coping
Group care activities as much as possible
Fatigue related to energy expenditure during labor and birth
Orient the patient and family to the labor and birth unit
Anxiety related to labor and the birthing process
Encourage frequent voiding and catheterize if necessary
Risk for impaired urinary elimination
