A woman who is gravida 3 para 2 arrives on the intrapartum unit. What is the most important nursing assessment at this time? Show a. Contraction pattern, amount of discomfort, and pregnancy history Recommended textbook solutions
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Terms in this set (20)Increase in estrogen Rationale: Theory suggests that increased estrogen levels allow the myometrium to become more sensitive to oxytocin. This sensitivity allows for the initiation of uterine contractions. In labor, progesterone levels decrease, not increase. Theory suggests that decreased progesterone levels increase myometrial contractility. Research shows an association between prostaglandin-producing agents stored in the fetal membranes and the onset of labor. Corticosteroids are increased during pregnancy and labor. A client at 39 weeks of gestation is demonstrating signs of labor. Which hormonal action is responsible for the onset of labor? Increase in progesterone Increase in estrogen Decrease in corticosteroids Decrease in prostaglandins Cervical dilation Rationale: Signs of preterm labor include cervical dilation, abdominal pain, diarrhea, lower back pain, pelvic pressure, and increased vaginal discharge. Headaches, elevated blood pressure, and decreased fetal movement are not clinical manifestations of preterm labor. A pregnant client is admitted to the hospital in premature labor. Which assessment finding should the nurse anticipate? Cervical dilation Elevated blood pressure Decreased fetal movement Headache Braxton Hicks contractions Loss of cervical mucus plug Lightening Bloody show Rationale: Lightening occurs as the fetus descends or drops down into the maternal pelvis. Bloody show usually occurs within 48 hours of the onset of true labor, and is also associated with the loss of the cervical mucus plug. Braxton Hicks contractions, or false labor, occur as the body is priming itself for the impending labor and delivery. Prior to the onset of labor, women generally have a surge of energy. The nurse is assessing a client at 38 weeks of gestation. Which premonitory signs may occur before the onset of labor? (Select all that apply.) Braxton Hicks contractions Loss of cervical mucus plug Lightening Fatigue Bloody show Lengthening of the umbilical cord Change in shape of the uterus from a disk to a globe Increased pain with contractions Rationale: Delivery of the placenta usually takes place within 30 minutes of birth. Signs that the placenta is about to deliver include increased pain with contractions, lengthening of the umbilical cord, and a change in shape of the uterus from a disk to a globe. Which sign is associated with the impending delivery of the placenta? (Select all that apply.) Change in shape of the uterus from a globe to a disk Lengthening of the umbilical cord Change in shape of the uterus from a disk to a globe Increased pain with contractions Decreased pain with contractions Every 2 minutes or less Rationale: Tachysystole, also known as hypertonic contractions, is defined as spontaneous or stimulated uterine activity that is excessive in nature. It is characterized by contractions occurring every 2 minutes or less. The other time frames listed are not characteristic of uterine tachysystole. A client is experiencing a hypertonic uterine contraction pattern. Which time frame correctly describes how often the contractions are occurring? Less than 5 minutes apart Less than 6-8 minutes between contractions Every 3-5 minutes Every 2 minutes or less Rationale: With only a minimal contracture of the pelvis, a trial of labor is indicated, and, if not successful, a cesarean birth will be performed. Introducing the concept of the trial of labor but mentioning the possibility of a cesarean birth if the trial is not successful is a positive and informative response. Telling the client that she can deliver vaginally or will have to have a cesarean birth is inaccurate information. The nurse cannot assume that the client will not be successful with a trial of labor. Making a statement to a client such as, "It might be possible to have a vaginal delivery, but I would count on a cesarean delivery," is not therapeutic and is inaccurate information. A client is told that her pelvic diameters are "slightly" contracted. The client asks the nurse how this will impact the birth plan. Which response by the nurse is the most appropriate? "You will have to have a cesarean delivery." "You can deliver vaginally." "It might be possible to have a vaginal delivery, but I would count on a cesarean delivery." "You will have a trial of labor first; a cesarean delivery will occur if the trial is not successful." "Due to the risk factors a cesarean birth has, it is only recommended if the benefits clearly outweigh the risks." Rationale: The most appropriate response to the client is, "Due to the risk factors a cesarean birth has, it is only recommended if the benefits clearly outweigh the risks." Cesarean births have a higher risk of bleeding, infection, and injury to other structures. Future pregnancy may be complicated by uterine scar separation and placenta accreta. Furthermore, risks to the mother increase with each consecutive surgery. The other statements provide inaccurate information to the client. The nurse is admitting a client for an induction of labor. The client asks if it would just be easier to have a cesarean birth because she is afraid of the pain. Which response from the nurse is most appropriate? "Due to the risk factors a cesarean birth has, it is only recommended if the benefits clearly outweigh the risks." "You should avoid having a cesarean birth at all costs. Your body is designed to give birth." "The process of inducing your labor could take several days. Would you like to speak to your obstetrician?" "That will be so much more convenient for you. Then you can schedule the delivery of your next baby by repeat cesarean." Encouraging fluids by mouth Rationale: This client is in the latent phase of the first stage of labor. During this time, it is normal for cervical dilation to progress at less than 1 cm every 2 hours. A prolonged latent phase may be treated with therapeutic rest and hydration. It is not necessary to augment the client's labor with oxytocin or prepare for a cesarean delivery. Rupturing membranes at a ?2 station places the client at risk for a prolapsed cord. The nurse is admitting a client at 39 weeks of gestation scheduled for a trial of labor after a previous cesarean birth who reports having uncomfortable contractions for a whole day and sleeplessness at night. The client's cervix is 3 cm, 50% effaced, and the baby is at -2 station. The baby's heart rate is 144 beats/min and contractions are palpable every 5-7 minutes. Which describes the nurse's anticipated action? Initiating IV oxytocin Encouraging fluids by mouth Assisting with artificial rupture of membranes Preparing for a possible cesarean delivery Provide sips of fluids or ice chips. Rationale: Sips of fluids or ice chips may be used to provide moisture and relieve dryness of the mouth. Applying cool, not warm, cloths to the face and forehead may help to cool the woman involved in the intense physical exertion of pushing. The client is not encouraged to ambulate in the second stage of labor, but instead to rest in between pushing. The nurse and support person can assist the woman into a pushing position with each contraction to further conserve energy. Between contractions, the woman should be assisted into a comfortable position. The nurse is preparing to care for a client in the second stage of labor. Which comfort measures should the nurse implement in the plan of care? Assist the client in maintaining a pushing position. Encourage ambulation. Apply warm cloths to the face and forehead. Provide sips of fluids or ice chips. Fluids and foods may be offered. Rationale: It is unnecessary to restrict intake in any way for the client that is low risk in the latent phase of labor. Furthermore, evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. The nurse is caring for a low-risk client in the latent phase of labor. The client states, "I am hungry and would like something light to eat." Which describes the nurse's understanding of fluid and nutritional intake during labor? Fluid and foods are avoided during labor. The client can have only fluids and ice chips. The client can have only ice chips. Fluids and foods may be offered. Repositioning the mother laterally Rationale: Reposition the mother to improve uteroplacental perfusion and then implement continuous fetal monitoring to evaluate the intervention. An FHR of 90 beats/min is abnormally low. Any abnormalities detected by intermittent auscultation require further evaluation by continuous electronic monitoring. Obtaining maternal vital signs and notifying the healthcare provider are all appropriate responses to FHR abnormalities, but uteroplacental perfusion is a key to providing the fetus with adequate oxygenation while implementing continuous fetal monitoring to evaluate the effectiveness of the intervention. The nurse auscultates the fetal heart rate (FHR) with a Doppler for a client in active labor, and determines that it is 90 beats/min. Which action should the nurse identify as a priority? Calling the healthcare provider Repositioning the mother laterally Taking the mother's blood pressure Applying a continuous electronic fetal monitor Reposition the ultrasound transducer. Rationale: The nurse will reposition the ultrasound transducer to obtain a continuous fetal heart rate tracing. A nonreassuring fetal heart rate pattern cannot be identified with an intermittent tracing. A suspected fetal arrhythmia may not be noted with an intermittent tracing. It is not necessary to reposition the mother on her left side to improve uteroplacental perfusion unless the tracing is nonreassuring. The nurse is caring for a client who is undergoing a labor induction and reports feeling uncomfortable. The client declines analgesia, instead preferring to walk and change positions frequently. The nurse notes frequent gaps in the fetal heart rate tracing and sections showing wide disparities in baseline fetal heart rate. Which action should the nurse take? Position the mother on her left side for maximum uteroplacental perfusion. Continue to monitor the client. Reposition the ultrasound transducer. Notify the healthcare provider of a suspected fetal arrhythmia. Rationale: The nurse's response to the client's question is, "The provider will rupture the amniotic membrane to stimulate your labor." An amniotomy is the artificial rupture of the amniotic membrane (AROM) to augment labor. Stripping the membranes involves the healthcare provider inserting a gloved finger into the internal os of the cervix and rotating it to separate the membranes from the lower uterine segment. Telling the client to ask the provider when they arrive is not a therapeutic response. Identifying the fetal station during a vaginal examination enables the provider to determine the relationship of the fetus to the maternal pelvis. The nurse is caring for a client who will have an amniotomy performed. The client states to the nurse, "I know my healthcare provider explained this earlier, but I am not sure what the procedure is." How should the nurse respond? "It is a procedure that is done to identify where the baby is in relation to your pelvis." "The provider will rupture the amniotic membrane to stimulate your labor." "You can ask the provider that question when they get here." "Your provider is going to strip the membranes." Setting up for an instrument-assisted delivery Rationale: A client who has made no progress in the second stage of labor and is at +3 station may require an instrument-assisted delivery. Perineal hygiene and emotional support will not facilitate the delivery. A full bladder can impede delivery, but there is no indication that this is the case at this time. The nurse is caring for a client in the second stage of labor who is at +3 station, but has not made further progress over the last 3 hours. The nurse notifies the healthcare provider. Which action should the nurse anticipate the healthcare provider to order? Setting up for an instrument-assisted delivery Inserting a urinary catheter to empty the bladder Perineal hygiene Emotional support Pushing the presenting part away to avoid cord compression Rationale: The nurse's initial action is to apply pressure on the presenting part to avoid fetal cord compression. An amnioinfusion will not resolve the issue of a prolapsed cord. Discontinuing the oxytocin administration is appropriate, but it is not the nurse's initial action. Providing oxygen to the mother may help fetal oxygenation status; however, it is not the initial nursing intervention. A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. Which should be the nurse's initial action? Administering oxygen via face rebreather at 15 L/min Stopping oxytocin administration immediately Pushing the presenting part away to avoid cord compression Preparing for an amnioinfusion Fundal assessment Rationale: During the fourth stage of labor, the nurse's priority is a fundal assessment. The fundus should be firm and midline about midway between the symphysis pubis and umbilicus. During the fourth stage of labor, nurses can expect changes in the maternal vital signs. The nurse should expect to perform assessments every 15 minutes × 4, then every 30 minutes × 2, then every hour until stable. The nurse will expect moderate vaginal drainage (lochia rubra). The woman may report feeling chilly, thirsty, hungry, and tired. The nurse is caring for a client going into the fourth stage of labor. Which is a priority nursing assessment during this stage? Hourly maternal vital signs Fundal assessment Oxygen saturation every 4 hours Vaginal discharge assessment every 4 hours Offering encouragement and support Rationale: During the second stage of labor the client requires encouragement and support. The client at a +5 station is an imminent delivery. Providing sips of water, applying extra blankets for warmth, and frequent perineal cleansing are not priorities at this time. The nurse is caring for a client in the second stage of labor and at a +5 station. The client appears overwhelmed and is experiencing perineal burning. Which action is a priority for the nurse at this time? Applying extra blankets for warmth Offering encouragement and support Providing frequent sips of water Providing frequent perineal cleansing "What are your expectations of this pregnancy?" Rationale: The woman's psyche or emotional state can affect her response to the labor and delivery process. The nurse can evaluate the client's emotional state with the question, "What are your expectations of this pregnancy?" Asking the client about likes or dislikes or baby names is not a direct assessment of the client's emotional state. Encouraging the client to walk is not an assessment of an emotional state. The nurse is performing an admission assessment on a client in early labor. Which question should the nurse ask to evaluate the client's emotional state? "Walking may take your mind off the contractions." "Have you chosen a name for the baby yet?" "How do you like this hospital?" "What are your expectations of this pregnancy?" Assessing the amniotic fluid Rationale: The nurse's role during an amniotomy is to document the characteristics of the amniotic fluid as well as monitor the fetal heart rate (FHR). The characteristics of amniotic fluid that are noted include its color, odor, and quantity. Perineal care is important but not the most important thing to do during an amniotomy. The Bishop score is not necessary prior to an amniotomy for a client who is 4 cm dilated. If an epidural is in place prior to an amniotomy, decreasing the dose is not within in the scope of practice for nursing and is not necessary. The nurse is caring for a client who is 4 cm dilated. The healthcare provider performs an amniotomy to augment the client's labor. Which correctly describes the nurse's role during an amniotomy? Assessing the amniotic fluid Decreasing the epidural dose Providing perineal care Evaluating the Bishop score Continuing monitoring Rationale: The most appropriate response by the nurse is to continue monitoring the client. The nurse providing care for a client in active labor notes a gradual decline in the fetal heart rate, beginning with the onset of a contraction and followed by a gradual return to baseline by the end of the contraction. Which is the most appropriate nursing response? Continuing monitoring Preparing for operative delivery Notifying the healthcare provider Administering oxygen Sets found in the same folderPostpartum NCLEX Style Questions20 terms christa_hinton OB NCLEX - Newborn Care20 terms glenndryden OB Postpartum NCLEX Questions52 terms ashley_coots7 Ch 6 OB - Introduction to Maternity and Pediatric…84 terms jonicaspers Other sets by this creatorPearson - Burns - NCLEX20 terms glenndryden Pearson - ARDS - NCLEX18 terms glenndryden Lewis - Inflammation/Wound Healing - Ch 1121 terms glenndryden Lewis - Integumentary Problems - Ch 2325 terms glenndryden Recommended textbook solutionsThe Human Body in Health and Disease7th EditionGary A. Thibodeau, Kevin T. Patton 1,505 solutions Introduction to Global Health2nd EditionKathryn H Jacobsen 116 solutions Pharmacology: An Introduction8th EditionBarbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh 1,355 solutions Epidemiology 1012nd EditionRobert H Friis 152 solutions Other Quizlet setsANTH 101 Test 163 terms avaadamsss Natural Resources Chp 1316 terms scienceSES Urinary Pogils27 terms brit925 Real state study guide👍✨49 terms hello-e4 Related questionsQUESTION what does the foreman ovale do? 11 answers QUESTION What is lecithin-sphingomyelin (L/S) ratio and what does it represent? 6 answers QUESTION What is the role of the mucous plug? 9 answers QUESTION What is the main hormone during the luteal phase? 10 answers Which nursing action is performed during the second stage of labor?the second stage is the descent and rotation of the fetal head. Various maternal positions can facilitate rotation and descent if the woman is able to change her position. When mobility is limited or descent does not occur, the nurse needs to consider what might be delaying descent.
Which is the priority for nursing care during the second stage of labor quizlet?The second stage of labor is the pushing stage. The nurse should help the mother push effectively. The mother cannot breastfeed in the second stage of labor. Checking fetal position is not the highest priority during the second stage of labor.
What is the second stage of labor quizlet?The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. Your health care provider may ask you to push with each contraction.
Which clinical finding indicates that the client has reached the second stage of labor quizlet?A nulliparous woman will remain quiet with her eyes closed between contractions. Which clinical finding indicates that the client has reached the second stage of labor? Woman experiences a strong urge to bear down.
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Which actions are additional responsibilities of the nurse in the second stage of labor quizlet?
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