OB Exam 2 Flashcards
A client in the first stage of labor asks her nurse for medication for pain. Which nursing action should be performed FIRST?
Obtain a vaginal exam to determine labor progress.
A nurse is caring for a client who just entered the third stage of labor. Which nursing action is the PRIORITY at this time?
Observe the perineum for a gush of blood and lengthening of the cord.
What do the following strategies have in common?
- Transcutaneous Electronic Nerve Stimulation (TENS)
- Aromatherapy
- Abdominal effleurage
- Warm compresses
They all use the gate-control theory.
A nurse caring for a client in labor at full term notes repeated smooth decreases in the fetal heart beat after every contraction.
Which nursing action should the nurse take FIRST?
Change the patient’s position to lateral or hands and knees.
A nurse is performing a non-stress test (NST) on a client with a full term pregnancy and decreased fetal movement. The nurse notes baseline fetal heart rate of 160 with minimal variability, no decelerations, and no accelerations. Which documentation and action are correct?
Non-reactive NST. The nurse should obtain a prescription for CST.
A pregnant client at full term calls the hospital thinking she is in labor. When should the nurse urge the client to come to the hospital immediately?
Strong contractions every 4 minutes, lasting about 1 minute.
A fetal presenting part is palpated at 2 cm ABOVE the ischial spines. Which documentation of fetal station is correct?
-2
Which of the seven cardinal movements is occurring immediately after the fetal head is born?
External rotation
The nurse is evaluating a client at full term who describes underwear wet with clear fluid an hour ago. Which finding would suggest intact fetal membranes?
Absence of ferning pattern on microscope slide of dried vaginal fluid.
A nurse performs a vaginal exam on a client in labor, noting the cervix is 2 cm dilated and 50% effaced at -2 station. What characteristics should the nurse anticipate during this phase of labor?
Talkative, eager, and calm between contractions.
A nurse has assisted her exhausted client with vacuum delivery of the fetal head. What action will the nurse anticipate next?
McRoberts maneuver
A nurse monitoring a patient in labor notes a sudden drop in fetal heart rate, then the patient stops breathing. What action should the nurse take?
Perform CPR
What are the 5 P’s of labor?
- Passenger
-Passageway
-Powers
-Position of mother
-Psychological response
What would 0 station indicate?
The presenting part of the fetus is even w/ the ischial spines.
What are the 5 obstetric emergencies?
- Meconium-Stained Amniotic Fluid (MSAF)
- Shoulder Dystocia (baby stuck)
- Prolapsed Umbilical Cord
- Rupture of Uterus
- Amniotic Fluid Embolism
A nurse is caring for a patient that is in active labor. The nurse sees the umbilical cord before the head, what is the priority action?
Elevate the fetal head your fingers.
A patient is having her 2nd baby and says she is sad that she can’t deliver vaginally because she previously had a C-Section. How should the nurse respond?
Inform the patient that it is possible to deliver vaginally after Cesarean. This is called Vaginal Birth After Cesarean (VBAC).
What characterizes a normal baseline fetal heart rate.
Baseline is average of rate over a 10 minute period, excluding accelerations/decelerations, makes variability, and areas of baseline that vary more than 25 bpm. (Use straight edge)
For the 5 P’s of labor, what factors facilitate a normal vaginal birth?
- Cephalic presentation, longitudinal lie, general flexion, R or L occiput anterior
- Station +4 or +5, fully effaced and dilated
- Contractions and involuntary pushing (Ferguson Reflex)
- Standing or squatting
- Has support, is where she wants to be, is properly prepared for birth, and fears have been addressed.
A nurse is caring for a patient on the OB unit. The patient is having irregular contractions that change based on activity, has no discharge or bleeding, and has not had any progressing cervical changes. What type of labor is this?
False labor.
What is a main difference to consider when determining true vs. false labor?
Someone in true labor has progressing cervical changes, someone in false labor will not.
A nurse hears a co-worker discussing “back labor”. The nurse should know that this is related to what fetal position?
Occiput posterior.
A nurse is caring for a mother and fetus on the unit. The occiput of the fetus is in a posterior position, what is the best position for the mother?
Hands and knees.
T or F: If a patient’s water breaks, that means they are in labor.
False.
