Chapter 18: Fetal Assessment During Labor Lowdermilk: Maternity & Womens Womens !ealth Care" 11th #dition M$L%'L# C!(C#
1. What is the most likely cause for early decelerations in the fetal heart rate (FHR)
pattern?
a.
Altered fetal cerebral blood flow
b. mbilical cord compression
c.
teroplacental insufficiency
d. !pontaneous rupture of membranes
A"!# A
$arly decelerations are the fetus% response to fetal head compression& these are considered beni'n and interentions are not necessary. *a *ariable decelerations are associated with umbilical cord compression. +ate decelerations are associated with uteroplacental insufficiency. insufficiency. !pontaneous rupture of membranes has no bearin' on the FHR unless the umbilical cord prolapses which would result in ariable or prolon'ed bradycardia. ,-F# o'nitie +eel# nderstand R$F# p. /10 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance 5. Which clinical findin' or interention mi'ht be considered the rationale for fetal
tachycardia to occur?
a.
4aternal feer
b. mbilical cord prolapse
c.
Re'ional anesthesia
d. 4a'nesium sulfate administratio ad ministration n
A"!# A
Fetal tachycardia can be considered an early si'n of fetal hypo6emia and may also result from maternal or fetal infection. mbilical cord prolapse re'ional anesthesia and the administration of ma'nesium sulfate will each more likely result in fetal bradycardia not tachycardia. ,-F# o'nitie +eel# nderstand R$F# p. /17 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance 8. While ealuatin' an e6ternal monitor tracin' of a woman in actie labor the nurse
notes that the FHR for fie se9uential contractions be'ins to decelerate late in the contraction with the nadir of the decelerations occurrin' after the peak of the contraction. What is the nurse%s first nurse%s first priority? priority?
a.
han'e the woman%s position.
b. "otify the health care proider. proider.
c.
Assist with amnioinfusion
a.
4aternal feer
b. mbilical cord prolapse
c.
Re'ional anesthesia
d. 4a'nesium sulfate administratio ad ministration n
A"!# A
Fetal tachycardia can be considered an early si'n of fetal hypo6emia and may also result from maternal or fetal infection. mbilical cord prolapse re'ional anesthesia and the administration of ma'nesium sulfate will each more likely result in fetal bradycardia not tachycardia. ,-F# o'nitie +eel# nderstand R$F# p. /17 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance 8. While ealuatin' an e6ternal monitor tracin' of a woman in actie labor the nurse
notes that the FHR for fie se9uential contractions be'ins to decelerate late in the contraction with the nadir of the decelerations occurrin' after the peak of the contraction. What is the nurse%s first nurse%s first priority? priority?
a.
han'e the woman%s position.
b. "otify the health care proider. proider.
c.
Assist with amnioinfusion
d. -nsert a scalp electrode.
A"!# A
+ate FHR decelerations may be caused by maternal supine hypotension syndrome. hese decelerations are usually corrected when the woman turns onto her side to displace the wei'ht of the 'raid uterus from fro m the ena caa. -f the fetus does not respond to primary nursin' interentions for late decelerations then the nurse should continue with subse9uent intrauterine resuscitation measures and notify the health care proider. An An amnioinfusion may be used to reliee pressure on an umbilical cord that has not prolapsed. he FHR pattern associated with this situation most likely will reeal ariable decelerations. Althou'h a fetal scalp electrode will proide accurate data for ealuatin' the well:bein' of the fetus it is not a nursin' interention that will alleiate late decelerations nor is it the nurse%s first priority. ,-F# o'nitie +eel# Apply R$F# p. /55 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance /. What is the most likely cause for ariable FHR decelerations?
a.
Altered fetal cerebral blood flow
b. mbilical cord compression
c.
teroplacental insufficiency
d. Fetal hypo6emia
A"!# ;
*ariable FHR decelerations can occur at any time durin' the uterine contractin' phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. teroplacental insufficiency results in late decelerations in the FHR. Fetal hypo6emia initially results in tachycardia and then bradycardia if hypo6ia continues. ,-F# o'nitie +eel# Remember R$F# p. /55 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance <. he nurse proidin' care for a hi'h:risk laborin' woman is alert for late FHR
decelerations. Which clinical findin' mi'ht be the cause for these late decelerations?
a.
Altered cerebral blood flow
b. mbilical cord compression
c.
teroplacental insufficiency
d. 4econium fluid
A"!#
teroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. mbilical cord compression results in ariable FHR decelerations. 4econium:stained fluid may or may not produce chan'es in the FHR dependin' on the 'estational a'e of the fetus and whether other causatie factors associated with fetal distress are present. ,-F# o'nitie +eel# nderstand R$F# p. /51 23# "ursin' 3rocess# Assessment
4!# lient "eeds# 3hysiolo'ic -nte'rity Health 3romotion and 4aintenance =. Which alteration in the FHR pattern would indicate the potential need for an
amnioinfusion?
a.
*ariable decelerations
b. +ate decelerations
c.
Fetal bradycardia
d. Fetal tachycardia
A"!# A
Amnioinfusion is used durin' labor to either dilute meconium:stained amniotic fluid or supplement the amount of amniotic fluid to reduce the seerity of ariable FHR decelerations caused by cord compression. +ate decelerations are unresponsie to amnioinfusion. Amnioinfusion Amnioinfusion is not appropriate for the treatment of fetal bradycardia and has no bearin' on fetal f etal tachycardia. ,-F# o'nitie +eel# Remember R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance >. Which FHR findin' is the most concernin' to the nurse who is proidin' care to a
laborin' client?
a.
Accelerations with fetal moement
b. $arly decelerations
c.
Aera'e FHR of 15= beats per minute
d. +ate decelerations
A"!# ,
+ate decelerations are caused by uteroplacental insufficiency and are associated with fetal hypo6emia. +ate FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal moement are an indication of fetal well:bein'. $arly decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelic outlet& they are not 'enerally a concern durin' normal labor. An An FHR findin' of 15= beats per minute is normal and not a concern. ,-F# o'nitie +eel# Analye R$F# p. /51 23# "ursin' 3rocess# Assessment Assessment 4!# lient "eeds# Health 3romotion and 4aintenance @. What three measures should the nurse implement to proide intrauterine
resuscitation?
a.
all the proider reposition the mother and perform a a'inal e6amination.
b. urn the client onto her side proide o6y'en (2 5) ia face mask and
increase intraenous (-*) fluids.
c.
Administer 25 to the mother increase -* fluids and notify the health care proider.
d. 3erform a a'inal e6amination e6a mination reposition the mother and proide 2 5
ia face mask.
A"!# ;
;asic interentions for the mana'ement of any abnormal FHR pattern include administerin' 2 5 ia a nonrebreather face mask at a rate of @ to 10 +min assistin' the woman onto a side:lyin' (lateral) position and increasin' blood olume by increasin' the rate of the primary -* infusion. he purpose of these interentions is to improe uterine blood flow and interillous space blood flow and to increase maternal o6y'enation and cardiac output. he term intrauterine resuscitation resuscitation is is sometimes used to refer to these interentions. -f these interentions do not 9uickly resole the abnormal FHR issue then the primary proider should be immediately notified. ,-F# o'nitie +eel# Analye R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 3hysiolo'ic -nte'rity 7. he nurse who proides care to clients in labor must hae a thorou'h understandin'
of the physiolo'ic processes of maternal hypotension. Which outcome mi'ht occur if the interentions for maternal hypotension are inade9uate?
a.
$arly FHR decelerations
b. Fetal arrhythmias
c.
teroplacental insufficiency
d. !pontaneous rupture of membranes
A"!#
+ow maternal blood pressure reduces placental blood flow durin' uterine contractions resultin' in fetal hypo6emia. 4aternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. !pontaneous rupture of membranes is not a result of maternal hypotension. ,-F# o'nitie +eel# nderstand R$F# p. /51 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 10. What are the le'al responsibilities of the perinatal nurses?
a.
orrectly interpretin' FHR patterns initiatin' appropriate nursin' interentions and documentin' the outcomes
b. Breetin' the client on arrial assessin' her status and startin' an -*
line
c.
Applyin' the e6ternal fetal monitor and notifyin' the health care proider
d. $nsurin' that the woman is comfortable
A"!# A
"urses who care for women durin' childbirth are le'ally responsible for correctly interpretin' FHR patterns initiatin' appropriate nursin' interentions based on those patterns and documentin' the outcomes of those interentions. Breetin' the client on arrial assessin' her and startin' an -* line are actiities that should be performed when any client arries to the maternity unit. he nurse is not the only one le'ally responsible for performin' these functions. Applyin' the e6ternal fetal monitor and notifyin' the health care proider is a nursin' function that is part of the standard of care for all obstetric clients and falls within the re'istered nurse%s scope of practice. $eryone carin' for the pre'nant woman should ensure that both she and her support partner are comfortable.
,-F# o'nitie +eel# nderstand R$F# p. /5/ 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# !afe and $ffectie are $nironment 11. he perinatal nurse realies that an FHR that is tachycardic bradycardic has late
decelerations or loss of ariability is nonreassurin' and is associated with which condition?
a.
Hypotension
b. ord compression
c.
4aternal dru' use
d. Hypo6emia
A"!# ,
"onreassurin' FHR patterns are associated with fetal hypo6emia. Fetal bradycardia may be associated with maternal hypotension. *ariable FHR decelerations are associated with cord compression. 4aternal dru' use is associated with fetal tachycardia. ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 15. A new client and her partner arrie on the labor deliery recoery and postpartum
(+,R3) unit for the birth of their first child. he nurse applies the electronic fetal monitor ($F4) to the woman. Her partner asks you to e6plain what is printin' on the 'raph referrin' to the $F4 strip. He wants to know what the baby%s heart rate should be. What is the nurse%s best response?
a.
D,on%t worry about that machine& that%s my Eob.
b. Dhe baby%s heart rate will fluctuate in response to what is happenin'
durin' labor.
c.
Dhe top line 'raphs the baby%s heart rate and the bottom line lets me
know how stron' the contractions are.
d. DGour physician will e6plain all of that later.
A"!# ;
$6plainin' what indicates a normal FHR teaches the partner about fetal monitorin' and proides support and information to alleiate his fears. ellin' the partner not to worry discredits his feelin's and does not proide the teachin' he is re9uestin'. ellin' the partner that the 'raph indicates how stron' the contractions are proides inaccurate information and does not address the partner%s concerns about the FHR. he $F4 'raphs the fre9uency and duration of the contractions not their intensity. "urses should take eery opportunity to proide teachin' to the client and her family especially when information is re9uested. ,-F# o'nitie +eel# Apply R$F# p. /1> 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3sychosocial -nte'rity 18. Which statement best describes a normal uterine actiity pattern in labor?
a.
ontractions eery 5 to < minutes
b. ontractions lastin' appro6imately 5 minutes
c.
ontractions appro6imately 1 minute apart
d. ontraction intensity of appro6imately <00 mm H' with rela6ation at
<0 mm H'
A"!# A
2erall contraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes of labor with lower fre9uencies durin' the first sta'e and hi'her fre9uencies obsered durin' the second sta'e. ontraction duration remains fairly stable throu'hout the first and second sta'es ran'in' from /< to @0 seconds 'enerally not e6ceedin' 70 seconds. ontractions 1 minute apart are occurrin' too often and would be considered an abnormal labor pattern. he intensity of uterine contractions 'enerally ran'es from 5< to <0 mm H' in the first sta'e of labor and may rise to more than @0 mm H' in the second sta'e. ,-F# o'nitie +eel# Remember R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 1/. he nurse is usin' intermittent auscultation (-A) to locate the fetal hea rtbeat.
Which statement re'ardin' this method of sureillance is accurate?
a.
he nurse can be e6pected to coer only two or three clients when -A is the primary method of fetal assessment.
b. he best course is to use the descriptie terms associated with $F4
when documentin' results.
c.
-f the heartbeat cannot be immediately found then a shift must be made to $F4.
d. ltrasound can be used to find the FHR and to reassure the mother if
the initial difficulty is a factor.
A"!# ,
+ocatin' fetal heartbeats often takes time. 4others can be erbally reassured and reassured by iewin' the ultrasound pictures if that deice is used to help locate the heartbeat. When used as the primary method of fetal assessment -A re9uires a nurse: to:client ratio of one to one. ,ocumentation should use only terms that can be numerically defined& the usual isual descriptions of $F4 are inappropriate. ,-F# o'nitie +eel# nderstand R$F# p. /18 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 1<. What is a distinct adanta'e of e6ternal $F4?
a.
he ultrasound transducer can accurately measure short:term ariability and beat:to:beat chan'es in the FHR.
b. he tocotransducer can measure and record the fre9uency re'ularity
intensity and appro6imate duration of uterine contractions.
c.
he tocotransducer is especially aluable for measurin' uterine actiity durin' the first sta'e of labor.
d. 2nce correctly applied by the nurse the transducer need not be
repositioned een when the woman chan'es positions.
A"!#
he tocotransducer is aluable for measurin' uterine actiity durin' the first sta'e of labor and is especially true when the membranes are intact. !hort:term ariability and beat:to:beat chan'es cannot be measured with this technolo'y. he tocotransducer cannot measure and record the intensity of uterine contractions. he transducer must be repositioned when the woman or the fetus chan'es position. ,-F# o'nitie +eel# nderstand R$F# pp. /1/:/1< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 1=. Which client would not be a suitable candidate for internal $F4?
a.
lient who still has intact membranes
b. Woman whose fetus is well en'a'ed in the pelis
c.
3re'nant woman who has a comorbidity of obesity
d. lient whose ceri6 is dilated to / to < cm
A"!# A
For internal $F4 the membranes must hae ruptured and the ceri6 must be dilated at least 5 to 8 cm. he presentin' part must be low enou'h to allow placement of the spiral electrode necessary for internal $F4. he accuracy of $F4 is not affected by maternal sie. Howeer ealuatin' fetal well:bein' usin' e6ternal $F4 may be more difficult on an obese client. he client whose ceri6 is dilated to / to < cm is indeed a candidate for internal monitorin'. ,-F# o'nitie +eel# nderstand R$F# p. /1= 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 1>. ,urin' labor a fetus displays an aera'e FHR of 18< beats per minute oer a 10:
minute period. Which statement best describes the status of this fetus?
a.
;radycardia
b. "ormal baseline heart rate
c.
achycardia
d. Hypo6ia
A"!# ;
he baseline FHR is measured oer 10 minutes& a normal ran'e is 110 to 1=0 beats per minute. ;radycardia is a FHR less than 110 beats per minute for 10 minutes or lon'er. achycardia is a FHR hi'her than 1=0 beats per minutes for 10 minutes or lon'er. Hypo6ia is an inade9uate supply of o6y'en& no indication of hypo6ia e6ists with a baseline FHR in the normal ran'e. ,-F# o'nitie +eel# Remember R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 3hysiolo'ic -nte'rity 1@. A nurse carin' for a woman in labor should understand that absent or minimal
ariability is classified as either abnormal or indeterminate. Which condition related to decreased ariability is considered beni'n?
a.
3eriodic fetal sleep state
b. $6treme prematurity
c.
Fetal hypo6emia
d. 3ree6istin' neurolo'ic inEury
A"!# A
When the fetus is temporarily in a sleep state minimal ariability is present. 3eriodic fetal sleep states usually last no lon'er than 80 minutes. A woman in labor with e6treme prematurity may display a FHR pattern of minimal or absent ariability. Abnormal ariability may also be related to fetal hypo6emia and metabolic acidemia. on'enital anomalies or a pree6istin' neurolo'ic inEury may also result in absent or minimal ariability. 2ther possible causes mi'ht be central nerous system ("!) depressant medications narcotics or 'eneral anesthesia. ,-F# o'nitie +eel# nderstand R$F# p. /1@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 17. Which definition of an acceleration in the fetal heart rate (FHR) is accurate?
a.
FHR accelerations are indications of fetal well:bein' when they are periodic.
b. FHR accelerations are 'reater and lon'er in preterm 'estations.
c.
FHR accelerations are usually obsered with breech presentations when they are episodic.
d. An acceleration in the FHR presents a isually apparent and abrupt
peak.
A"!# ,
Acceleration of the FHR is defined as a isually apparent abrupt (only to peak 80 seconds) increase in the FHR aboe the baseline rate. 3eriodic accelerations occur with uterine contractions and are usually obsered with breech presentations. $pisodic accelerations occur durin' fetal moement and are indications of fetal well:bein'. 3reterm accelerations peak at 10 beats per minute aboe the baseline and last for at least 10 seconds. ,-F# o'nitie +eel# Remember R$F# p. /50 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 50. Which characteristic correctly matches the type of deceleration with its likely
cause?
a.
$arly decelerationumbilical cord compression
b. +ate decelerationuteroplacental insufficiency
c.
*ariable decelerationhead compression
d. 3rolon'ed decelerationunknown cause
A"!# ;
+ate deceleration is caused by uteroplacental insufficiency. $arly deceleration is caused by head compression. *ariable deceleration is caused by umbilical cord compression. 3rolon'ed deceleration has a ariety of either beni'n or critical causes. ,-F# o'nitie +eel# Remember R$F# pp. /50:/51 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 51. Which information related to a prolon'ed deceleration is important for the labor
nurse to understand?
a.
3rolon'ed decelerations present a continuin' pattern of beni'n decelerations that do not re9uire interention.
b. 3rolon'ed decelerations constitute a baseline chan'e when they last
lon'er than < minutes.
c.
A disruption to the fetal o6y'en supply causes prolon'ed decelerations.
d. 3rolon'ed decelerations re9uire the customary fetal monitorin' by the
nurse.
A"!#
3rolon'ed decelerations are caused by a disruption in the fetal o6y'en supply. hey usually be'in as a refle6 response to hypo6ia. -f the disruption continues then the fetal cardiac tissue itself will become hypo6ic resultin' in direct myocardial depression of the FHR. 3rolon'ed decelerations can be caused by prolon'ed cord compression uteroplacental insufficiency or perhaps sustained head compression. 3rolon'ed decelerations lastin' lon'er than 10 minutes are considered a baseline chan'e that may re9uire interention. A prolon'ed deceleration is a isually apparent decrease (may be either 'radual or abrupt) in the FHR of at least 1< beats per minute below the baseline and lastin' lon'er than 5 minutes but shorter than 10 minutes. "urses should immediately notify the physician or nurse:midwife and initiate appropriate treatment of abnormal patterns when they see prolon'ed decelerations. ,-F# o'nitie +eel# nderstand R$F# p. /55 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 55. -n which situation would the nurse be called on to stimulate the fetal scalp?
a.
As part of fetal scalp blood samplin'
b. -n response to tocolysis
c.
-n preparation for fetal o6y'en saturation monitorin'
d. o elicit an acceleration in the FHR
A"!# ,
he scalp can be stimulated usin' di'ital pressure durin' a a'inal e6amination. Fetal scalp blood samplin' inoles swabbin' the scalp with disinfectant before a sample is collected. he nurse stimulates the fetal scalp to elicit an acceleration of the FHR. ocolysis is rela6ation of the uterus. Fetal o6y'en saturation monitorin' inoles the insertion of a sensor. ,-F# o'nitie +eel# Apply R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 58. 3art of the nurse%s role is assistin' with pushin' and positionin'. Which 'uidance
should the nurse proide to her client in actie labor?
a.
$ncoura'e the woman%s cooperation in aoidin' the supine position.
b. Adise the woman to aoid the semi:Fowler position.
c.
$ncoura'e the woman to hold her breath and ti'hten her abdominal muscles to produce a a'inal response.
d. -nstruct the woman to open her mouth and close her 'lottis lettin' air
escape after the push.
A"!# A
he woman should maintain a side:lyin' position. he semi:Fowler position is the recommended side:lyin' position with a lateral tilt to the uterus. $ncoura'in' the woman to hold her breath and ti'hten her abdominal muscles is the *alsala maneuer which should be aoided. ;oth the mouth and 'lottis should be open allowin' air to escape durin' the push. ,-F# o'nitie +eel# Apply R$F# p. /5> 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 5/. -n which clinical situation would the nurse most likely anticipate a fetal
bradycardia?
a.
-ntraamniotic infection
b. Fetal anemia
c.
3rolon'ed umbilical cord compression
d. ocolytic treatment usin' terbutaline
A"!#
Fetal bradycardia can be considered a later si'n of fetal hypo6ia and is known to occur before fetal death. ;radycardia can result from placental transfer of dru's prolon'ed compression of the umbilical cord maternal hypothermia and maternal hypotension. -ntraamniotic infection fetal anemia and tocolytic treatment usin' terbutaline would most likely result in fetal tachycardia. ,-F# o'nitie +eel# nderstand R$F# p. /55 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 5<. Which nursin' interention would result in an increase in maternal cardiac output?
a.
han'e in position
b. 26ytocin administration
c.
Re'ional anesthesia
d. -* anal'esic
A"!# A
4aternal supine hypotension syndrome is caused by the wei'ht and pressure of the 'raid uterus on the ascendin' ena caa when the woman is in a supine position. his position reduces enous return to the woman%s heart as well as cardiac output and subse9uently reduces her blood pressure. he nurse can encoura'e the woman to chan'e positions and to aoid the supine position. 26ytocin administration re'ional anesthesia and -* anal'esic may reduce maternal cardiac output. ,-F# o'nitie +eel# Apply R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 5=. he nurse is ealuatin' the $F4 tracin' of the client who is in actie labor.
!uddenly the FHR drops from its baseline of 15< down to @0 beats per minute. he mother is repositioned and the nurse proides o6y'en increased -* fluids and performs a a'inal e6amination. he ceri6 has not chan'ed. Fie minutes hae passed and the FHR remains in the @0s. What additional nursin' measures should the nurse take ne6t?
a.
all for help.
b. -nsert a Foley catheter.
c.
!tart administerin' 3itocin.
d. -mmediately notify the care proider.
A"!# ,
o reliee an FHR deceleration the nurse can reposition the mother increase -* fluids and proide o6y'en. -f o6ytocin is infusin' then it should be discontinued. -f the FHR does not resole then the primary care proider should be immediately notified. -nsertin' a Foley catheter is an inappropriate nursin' action. -f the FHR were to continue in a nonreassurin' pattern then a cesarean section could be warranted which would re9uire a Foley catheter. Howeer the physician must make that determination. he administration of 3itocin may place additional stress on the fetus. ,-F# o'nitie +eel# Analye R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 5>. he nurse obseres a sudden increase in ariability on the $R4 tracin'. Which
class of medications may cause this findin'?
a. "arcotics
b. ;arbiturates
c.
4ethamphetamines
d. ran9uiliers
A"!#
"arcotics barbiturates and tran9uiliers may be causes of decreased ariability& whereas methamphetamines may cause increased ariability. ,-F# o'nitie +eel# nderstand R$F# p. /17 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 5@. What is the correct placement of the tocotransducer for effectie $F4?
a.
2er the uterine fundus
b. 2n the fetal scalp
c.
-nside the uterus
d. 2er the mother%s lower abdomen
A"!# A
he tocotransducer monitors uterine actiity and should be placed oer the fundus where the most intensie uterine contractions occur. he tocotransducer is for e6ternal use. ,-F# o'nitie +eel# nderstand R$F# p. /1/ 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 57. What physiolo'ic chan'e occurs as the result of increasin' the infusion rate of
nonadditie -* fluids?
a.
4aintainin' normal maternal temperature
b. 3reentin' normal maternal hypo'lycemia
c.
-ncreasin' the o6y'en:carryin' capacity of the maternal blood
d. $6pandin' maternal blood olume
A"!# ,
Fillin' the mother%s ascular system increases the amount of blood aailable to perfuse the placenta and may correct hypotension. -ncreasin' fluid olume may alter the maternal temperature only if she is dehydrated. 4ost -* fluids for laborin' women are isotonic and do not proide e6tra 'lucose. 26y'en:carryin' capacity is increased by addin' more red blood cells. ,-F# o'nitie +eel# Apply R$F# p. /5< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 80. he client has deliered by ur'ent caesarean birth for fetal compromise. mbilical
cord 'ases were obtained for acid:base determination. he pH is =.7 partial pressure of carbon dio6ide (32 5) is eleated and the base deficit is 11 mmol+. What type of acidemia is displayed by the infant?
a.
Respiratory
b. 4etabolic
c.
4i6ed
d. urbulent
A"!# A
hese findin's are eidence of respiratory acidemia. 4etabolic acidemia is e6pressed by a pH I>.50 normal carbon dio6ide pressure and a base e6cess of 15 mmol+. 4i6ed acidemia is eidenced by a pH I>.50 eleated carbon dio6ide pressure and a base e6cess of 15 mmol+. here is no such findin' as turbulent acidemia.
,-F# o'nitie +eel# Analye R$F# p. /5= 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity M$L%'L# )#*'(+*#
1. -n assessin' the immediate condition of the newborn after birth a sample of cord
blood may be a useful adEunct to the Ap'ar score. ord blood is then tested for pH carbon dio6ide o6y'en and base deficit or e6cess. Which clinical situation warrants this additional testin'? (Select all that apply.)
a.
+ow <:minute Ap'ar score
b. -ntrauterine 'rowth restriction (-BR)
c.
4aternal thyroid disease
d. -ntrapartum feer
e.
*acuum e6traction
A"!# A ; ,
he American olle'e of 2bstetricians and Bynecolo'ists (A2B) su''ests obtainin' cord blood alues in all of these clinical situations e6cept for a cuum e6tractions delieries. ord blood 'ases should also be performed for multifetal pre'nancies or abnormal FHR tracin's. !amples can be drawn from both the umbilical artery and the umbilical ein. Results may indicate that fetal compromise has occurred. ,-F# o'nitie +eel# nderstand R$F# p. /5= 23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 5. Accordin' to the "ational -nstitute of hild Health and Human ,eelopment
("-H,) hree:ier !ystem of FHR lassification cate'ory --- tracin's include all FHR tracin's not cate'oried as cate'ory - or --. Which characteristics of the FHR belon' in cate'ory ---? (Select all that apply.)
a.
;aseline rate of 110 to 1=0 beats per minute
b. achycardia
c.
Absent baseline ariability not accompanied by recurrent decelerations
d. *ariable decelerations with other characteristics such as shoulders or
oershoots
e.
Absent baseline ariability with recurrent ariable decelerations
f.
;radycardia
A"!# ; , $ F
achycardia ariable decelerations with other characteristics absent baseline ariability with recurrent ariable decelerations and bradycardia are characteristics that are considered nonreassurin' or abnormal and belon' in cate'ory ---. A FHR of 110 to 1=0 beats per minute is considered normal and belon's in cate'ory -. Absent baseline ariability not accompanied by recurrent decelerations is a cate'ory -characteristic. ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# Health 3romotion and 4aintenance 8. Which FHR decelerations would re9uire the nurse to chan'e the maternal position?
(Select all that apply.)
a.
$arly decelerations
b. +ate decelerations
c.
*ariable decelerations
d. 4oderate decelerations
e.
3rolon'ed decelerations
A"!# ; $
$arly decelerations (and accelerations) do not 'enerally need any nursin' interention. +ate decelerations su''est that the nurse should chan'e the maternal position (lateral). *ariable decelerations also re9uire a maternal position chan'e (side to side). 4oderate decelerations are not an accepted cate'ory. 3rolon'ed decelerations are late or ariable decelerations that last for a prolon'ed period (lon'er than 5 minutes) and re9uire interention. ,-F# o'nitie +eel# nderstand R$F# pp. /55 /58
23# "ursin' 3rocess# Assessment C "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance /. A tiered system of cate'oriin' FHR has been recommended by professional
or'aniations. "urses midwies and physicians who care for women in labor must hae a workin' knowled'e of fetal monitorin' standards and understand the si'nificance of each cate'ory. What is the correct nomenclature for these cate'ories? (Select all that apply.)
a.
Reassurin'
b. ate'ory -
c.
ate'ory --
d. "onreassurin'
e.
ate'ory ---
A"!# ; $
he three:tiered system of FHR tracin's include cate'ory - -- and ---. ate'ory - is a normal tracin' re9uirin' no action. ate'ory -- FHR tracin's are indeterminate and includes tracin's that do not meet cate'ory - or --- criteria. ate'ory --- tracin's are abnormal and re9uire immediate interention. ,-F# o'nitie +eel# nderstand R$F# p. /11 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity
<. he baseline FHR is the aera'e rate durin' a 10:minute se'ment. han'es in FHR
are cate'oried as periodic or episodic. hese patterns include both accelerations and decelerations. he labor nurse is ealuatin' the client%s most recent 10:minute se'ment on the monitor strip and notes a late deceleration. Which is likely to hae caused this chan'e? (Select all that apply.)
a.
!pontaneous fetal moement
b. ompression of the fetal head
c.
3lacental abruption
d. ord around the baby%s neck
e.
4aternal supine hypotension
A"!# $
Late decelerations are almost always caused by uteroplacental insufficiency. -nsufficiency is caused by uterine tachysystole maternal hypotension epidural or spinal anesthesia -BR intraamniotic infection or placental abruption. !pontaneous fetal moement a'inal e6amination fetal scalp stimulation fetal reaction to e6ternal sounds uterine contractions fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions fundal pressure a'inal e6amination and the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression which may happen when the umbilical cord is around the baby%s neck arm le' or other body part or when a short cord a knot in the cord or a prolapsed cord is present. ,-F# o'nitie +eel# Analye R$F# p. /55 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# ,ia'nosis
4!# lient "eeds# 3hysiolo'ic -nte'rity MA%C!+,
Fetal well:bein' in labor can be measured by the response of the FHR to uterine contractions. 4atch the characteristic of normal uterine actiity durin' labor with the correct description.
a.
Fre9uency
b. ,uration
c.
!tren'th
d. Restin' tone
e.
Rela6ation time
1. ommonly /< seconds or more in the second sta'e of labor 5. Benerally ran'in' from two to fie contractions per 10 minutes of labor 8. Aera'e of 10 mm H' /. 3eakin' at /0 to >0 mm H' in the first sta'e of labor <. Remainin' fairly stable throu'hout the first and second sta'es 1. A"!# $ ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# -f the FHR responds outside of these eidence:based parameters for uterine actiity durin' labor then interentions may be re9uired. ontraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes durin' labor with lower fre9uencies obsered in the first sta'e
of labor and hi'her fre9uencies durin' the second sta'e. ,uration of contractions remains fairly stable throu'hout the first and second sta'es and rarely e6ceeds 70 seconds. he stren'th of uterine contractions ran'es from /0 to >0 mm H' in the first sta'e and may rise to hi'her than @0 mm H' in the second sta'e. he restin' tone aera'es 10 mm H' and the uterus should feel soft if palpation is used. -n the first sta'e of labor rela6ation time is commonly =0 seconds o r lon'er and /< seconds or lon'er in the second sta'e. 5. A"!# A ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# -f the FHR responds outside of these eidence:based parameters for uterine actiity durin' labor then interentions may be re9uired. ontraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes durin' labor with lower fre9uencies obsered in the first sta'e of labor and hi'her fre9uencies durin' the second sta'e. ,uration of contractions remains fairly stable throu'hout the first and second sta'es and rarely e6ceeds 70 seconds. he stren'th of uterine contractions ran'es from /0 to >0 mm H' in the first sta'e and may rise to hi'her than @0 mm H' in the second sta'e. he restin' tone aera'es 10 mm H' and the uterus should feel soft if palpation is used. -n the first sta'e of labor rela6ation time is commonly =0 seconds o r lon'er and /< seconds or lon'er in the second sta'e. 8. A"!# , ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# -f the FHR responds outside of these eidence:based parameters for uterine actiity durin' labor then interentions may be re9uired. ontraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes durin' labor with lower fre9uencies obsered in the first sta'e of labor and hi'her fre9uencies durin' the second sta'e. ,uration of contractions remains fairly stable throu'hout the first and second sta'es and rarely e6ceeds 70 seconds. he stren'th of uterine contractions ran'es from /0 to >0 mm H' in the first sta'e and may rise to hi'her than @0 mm H' in the second sta'e. he restin' tone aera'es 10 mm H' and the uterus should feel soft if palpation is used. -n the first sta'e of labor rela6ation time is commonly =0 seconds o r lon'er and /< seconds or lon'er in the second sta'e. /. A"!# ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# -f the FHR responds outside of these eidence:based parameters for uterine actiity durin' labor then interentions may be re9uired. ontraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes durin' labor with lower fre9uencies obsered in the first sta'e of labor and hi'her fre9uencies durin' the second sta'e. ,uration of contractions remains fairly stable throu'hout the first and second sta'es and rarely e6ceeds 70 seconds. he stren'th of uterine contractions ran'es from /0 to >0 mm H' in the first sta'e and may rise to hi'her than @0 mm H' in the second sta'e. he restin' tone aera'es 10 mm H' and the uterus should feel soft
if palpation is used. -n the first sta'e of labor rela6ation time is commonly =0 seconds o r lon'er and /< seconds or lon'er in the second sta'e. <. A"!# ; ,-F# o'nitie +eel# Analye R$F# p. /11 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# -f the FHR responds outside of these eidence:based parameters for uterine actiity durin' labor then interentions may be re9uired. ontraction fre9uency 'enerally ran'es from two to fie contractions per 10 minutes durin' labor with lower fre9uencies obsered in the first sta'e of labor and hi'her fre9uencies durin' the second sta'e. ,uration of contractions remains fairly stable throu'hout the first and second sta'es and rarely e6ceeds 70 seconds. he stren'th of uterine contractions ran'es from /0 to >0 mm H' in the first sta'e and may rise to hi'her than @0 mm H' in the second sta'e. he restin' tone aera'es 10 mm H' and the uterus should feel soft if palpation is used. -n the first sta'e of labor rela6ation time is commonly =0 seconds o r lon'er and /< seconds or lon'er in the second sta'e
Chapter 1-: +ursing Care o. the Family During Labor and /irth Lowdermilk: Maternity & Womens !ealth Care" 11th #dition M$L%'L# C!(C#
1. Which statement by the client will assist the nurse in determinin' whether she is in
true labor as opposed to false labor?
a.
D- passed some thick pink mucus when - urinated this mornin'.
b. D4y ba' of waters Eust broke.
c.
Dhe contractions in my uterus are 'ettin' stron'er and closer to'ether.
d. D4y baby dropped and - hae to urinate more fre9uently now.
A"!#
Re'ular stron' contractions with the presence of cerical chan'e indicate that the woman is e6periencin' true labor. he loss of the mucous plu' (operculum) often occurs durin' the first sta'e of labor or before the onset of labor but it is not the indicator of true labor. !pontaneous rupture of membranes (R24) often occurs durin' the first sta'e of labor but it is not the indicator of true labor. he presentin' part of the fetus typically becomes en'a'ed in the pelis at the onset of labor but this is not the indicator of true labor. ,-F# o'nitie +eel# nderstand R$F# p. /81 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 5. When a nulliparous woman telephones the hospital to report that she is in labor
what 'uidance should the nurse proide or information should the nurse obtain?
a.
ell the woman to stay home until her membranes rupture.
b. $mphasie that food and fluid intake should stop.
c.
Arran'e for the woman to come to the hospital for labor ealuation.
d. Ask the woman to describe why she beliees she is in labor.
A"!# ,
Assessment be'ins at the first contact with the woman whether by telephone or in person. ;y askin' the woman to describe her si'ns and symptoms the nurse can be'in her assessment and 'ather data. he initial nursin' actiity should be to 'ather data about the woman%s status. he amniotic membranes may or may not spontaneously rupture durin' labor. he client may be instructed to stay home until the uterine contractions become stron' and re'ular. ;efore instructin' the woman to come to the hospital the nurse should initiate her assessment durin' the telephone interiew. After this assessment has been made the nurse may want to discuss the appropriate oral intake for early labor such as li'ht foods or clear li9uids dependin' on the preference of the client or her primary health care proider.
,-F# o'nitie +eel# Apply R$F# p. /8/ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 8. he nurse is carin' for a client in early labor. 4embranes ruptured appro6imately 5
hours earlier. his client is at increased risk for which complication?
a.
-ntrauterine infection
b. Hemorrha'e
c.
3recipitous labor
d. !upine hypotension
A"!# A
When the membranes rupture microor'anisms from the a'ina can ascend into the amniotic sac causin' chorioamnionitis and placentitis. R24 is not associated with fetal or maternal bleedin'. Althou'h R24 may increase the intensity of the contractions and facilitate actie labor it does not result in precipitous labor. R24 has no correlation with supine hypotension. ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# 3hysiolo'ic -nte'rity /. he uterine contractions of a woman early in the actie phase of labor are assessed
by an internal uterine pressure catheter (-3). he uterine contractions occur eery 8 to / minutes and last an aera'e of << to =0 seconds. hey are becomin' more re'ular and are moderate to stron'. ;ased on this information what would a prudent nurse do ne6t?
a.
-mmediately notify the woman%s primary health care proider.
b. 3repare to administer an o6ytocic to stimulate uterine actiity.
c.
,ocument the findin's because they reflect the e6pected contraction pattern for the actie phase of labor.
d. 3repare the woman for the onset of the second sta'e of labor.
A"!#
he nurse is responsible for monitorin' the uterine contractions to ascertain whether they are powerful and fre9uent enou'h to accomplish the work of e6pellin' the fetus and the placenta. -n addition the nurse documents these findin's in the client%s medical record. his labor pattern indicates that the client is in the actie phase of the first sta'e of labor. "othin' indicates a need to notify the primary health care proider at this time. 26ytocin au'mentation is not needed for this labor pattern& this contraction pattern indicates that the woman is in actie labor. Her contractions will eentually become stron'er last lon'er and come closer to'ether durin' the transition phase of the first sta'e of labor. he transition phase precedes the second sta'e of labor or deliery of the fetus. ,-F# o'nitie +eel# Apply R$F# p. /8= 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance <. Which action is correct when palpation is used to assess the characteristics and
pattern of uterine contractions?
a.
3lacin' the hand on the abdomen below the umbilicus and palpatin' uterine tone with the fin'ertips
b. ,eterminin' the fre9uency by timin' from the end of one contraction to
the end of the ne6t contraction
c.
$aluatin' the intensity by pressin' the fin'ertips into the uterine fundus
d. Assessin' uterine contractions eery 80 minutes throu'hout the first
sta'e of labor
A"!#
he nurse or primary health care proider may assess uterine actiity by palpatin' the fundal section of the uterus usin' the fin'ertips. 4any women may e6perience labor pain in the lower se'ment of the uterus which may be unrelated to the firmness of the contraction detectable in the uterine fundus. he fre9uency of uterine contractions is determined by palpatin' from the be'innin' of one contraction to the be'innin' of the ne6t contraction. Assessment of uterine actiity is performed in interals based on the sta'e of labor. As labor pro'resses this assessment is performed more fre9uently. ,-F# o'nitie +eel# Apply R$F# pp. //0://1 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance =. When assessin' a woman in the first sta'e of labor which clinical findin' will alert
the nurse that uterine contractions are effectie?
a.
,ilation of the ceri6
b. ,escent of the fetus to J5 station
c.
Rupture of the amniotic membranes
d. -ncrease in bloody show
A"!# A
he a'inal e6amination reeals whether the woman is in true labor. erical chan'e especially dilation in the presence of ade9uate labor indicates that the woman is in true labor. $n'a'ement and descent of the fetus are not synonymous and may occur before labor. R24 may occur with or without the presence of labor. ;loody show may indicate a slow pro'ressie cerical chan'e (e.'. effacement) in both true and false labor. ,-F# o'nitie +eel# nderstand R$F# p. /81 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# Health 3romotion and 4aintenance >. he nurse performs a a'inal e6amination to assess a client%s labor pro'ress. Which
action should the nurse take ne6t?
a.
3erform an e6amination at least once eery hour durin' the actie phase of labor.
b. 3erform the e6amination with the woman in the supine position.
c.
Wear two clean 'loes for each e6amination.
d. ,iscuss the findin's with the woman and her partner.
A"!# ,
he nurse should discuss the findin's of the a'inal e6a mination with the woman and her partner as well as report the findin's to the primary care proider. A a'inal
e6amination should be performed only when indicated by the status of the woman and her fetus. he woman should be positioned so as to aoid supine hypotension. he e6aminer should wear a sterile 'loe while performin' a a'inal e6amination for a laborin' woman. ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3sychosocial -nte'rity @. A multiparous woman has been in labor for @ hours. Her membranes hae Eust
ruptured. What is the nurse%s highest priority in this situation?
a.
3repare the woman for imminent birth.
b. "otify the woman%s primary health care proider.
c.
,ocument the characteristics of the fluid.
d. Assess the fetal heart rate (FHR) and pattern.
A"!# ,
he umbilical cord may prolapse when the membranes rupture. he FHR and pattern should be closely monitored for seeral minutes immediately after the R24 to ascertain fetal well:bein' and the findin's should be documented. he R24 may increase the intensity and fre9uency of the uterine contractions but it does not indicate that birth is imminent. he nurse may notify the primary health care proider after R24 occurs and the fetal well:bein' and response to R24 hae been assessed. he nurse%s priority is to assess fetal well:bein'. he nurse should document the characteristics of the amniotic fluid but the initial response is to assess fetal well: bein' and the response to R24. ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance
7. nder which circumstance should the nurse assist the laborin' woman into a hands:
and:knees position?
a.
2cciput of the fetus is in a posterior position.
b. Fetus is at or aboe the ischial spines.
c.
Fetus is in a erte6 presentation.
d. 4embranes hae ruptured.
A"!# A
he hands:and:knees position is effectie in helpin' to rotate the fetus from a posterior to an anterior position. 4any women e6perience the irresistible ur'e to push when the fetus is at the leel of the ischial spines. -n some cases this ur'e is felt before the woman is fully dilated. he woman should be instructed not to push until complete cerical dilation has occurred. "o one position is correct fo r childbirth. he two most common positions assumed by women are the sittin' and side:lyin' positions. he woman may be encoura'ed into a hands:and:knees position if the umbilical cord prolapsed when the membranes ruptured. ,-F# o'nitie +eel# Apply R$F# p. //7 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 10. A nulliparous woman has Eust be'un the latent phase of the second sta'e of her
labor. he nurse should anticipate which behaior?
a.
A nulliparous woman will e6perience a stron' ur'e to bear down.
b. 3erineal bul'in' will show.
c.
A nulliparous nulliparous woman will remain re main 9uiet with her eyes closed between contractions.
d. he amount of bri'ht red bloody show will increase.
A"!#
he woman is able to rela6 and close her eyes between contractions as the fetus passiely descends. he he woman may be ery 9uiet 9uiet durin' this phase. ,urin' ,urin' the latent phase of the second sta'e of of labor the ur'e to bear down is often often absent or only sli'ht sli'ht durin' the acme of the contractions. 3erineal bul'in' occurs durin' the transition phase of the second sta'e of of labor not at the be'innin' of the second sta'e. An An increase in bri'ht red bloody show occurs durin' the descent phase of the second sta'e of labor. ,-F# o'nitie +eel# nderstand R$F# p. /
labor?
a.
Amniotic membranes rupture.
b. eri6 cannot be felt durin' a a'inal e6amination. e6a mination.
c.
Woman Woman e6periences a stron' ur'e to bear down.
d. 3resentin' part of the fetus is below the ischial spines.
A"!#
,urin' the descent phase of the second sta'e of labor the woman may e6perience an increase in the ur'e to bear down. he R24 has no si'nificance in determinin' the sta'e of labor. he second sta'e of labor be'ins with full cerical dilation. 4any women may hae an ur'e to bear down when the presentin' fetal part is below the leel of the ischial spines. his ur'e can occur durin' the first sta'e of labor as early as with < cm dilation. ,-F# o'nitie +eel# nderstand R$F# p. /
he e6ternal fetal monitor shows uterine contractions eery
to / minutes. he
nurse reports this as what sta'e of labor?
a.
First sta'e latent phase
b. First sta'e actie phase
c.
First sta'e transition phase
d. !econd sta'e latent phase
A"!# ;
his maternal pro'ress indicates that the woman is in the actie phase of the first sta'e of labor. ,urin' the latent phase of the first sta'e of labor the e6pected maternal
pro'ress is 0 to 8 cm dilation dilation with contractions contractions eery < to 80 minutes. minutes. ,urin' the transition phase of the first sta'e of labor the e6pected maternal pro'ress is @ to 10 cm dilation with contractions eery 5 to 8 minutes. ,urin' the latent phase of the second sta'e of labor the woman is completely dilated and e6periences a restful period of Dlaborin' down. down. ,-F# o'nitie +eel# nderstand R$F# p. /8= 23# "ursin' 3rocess# Assessment Assessment 4!# lient "eeds# Health 3romotion and 4aintenance
critical nursin' action in carin' for the newborn immediately 18. What is the most critical after the birth?
a.
Keepin' the airway clear
b. Fosterin' parent:newborn attachment
c.
,ryin' the newborn and wrappin' the infant in a blanket
d. Administerin' eye drops and itamin K
A"!# A
he care 'ien immediately after the birth focuses on assessin' and stabiliin' the newborn. Althou'h Althou'h fosterin' parent:newborn attachment is an important task for the nurse it is not the most critical nursin' action in carin' for the newborn immediately after birth. he care 'ien immediately after birth focuses on assessin' and stabiliin' the newborn. he nursin' actiities are (in order of importance) to maintain a patent airway to support respiratory effort and to preent cold stress by dryin' the newborn and coerin' him or her with a warmed blanket or placin' the newborn under a radiant warmer. After After the newborn has been stabilied the nurse assesses the newborn%s physical physical condition wei'hs and measures the newborn administers prophylactic eye ointment ointment and a itamin K inEection inEection affi6es an identification identification bracelet wraps the newborn in warm blankets and then 'ies the newborn to the partner or to the mother of the infant.
,-F# o'nitie +eel# Apply R$F# p. /=/ 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 1/. What is the rationale for the administration of an o6ytocic (e.'. 3itocin
4ether'ine) after e6pulsion of the placenta?
a.
o reliee pain
b. o stimulate uterine contraction
c.
o preent infection
d. o facilitate rest and rela6ation
A"!# ;
26ytocics stimulate uterine contractions which reduce blood loss after the third sta'e of labor. 26ytocics are not used to treat pain do not preent infection and do not facilitate rest and rela6ation. ,-F# o'nitie +eel# Remember R$F# p. /== 23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 1<. Which description of the phases of the first sta'e of labor is most accurate?
a.
+atent# mild re'ular contractions& no dilation& bloody show
b. Actie# moderate re'ular contractions& / to > cm dilation
c.
+ull# no contractions& dilation stable
d. ransition# ery stron' but irre'ular contractions& @ to 10 cm dilation
A"!# ;
he actie phase is characteried by moderate and re'ular contractions / to > cm dilation and duration of 8 to = hours. he latent phase is characteried by mild:to: moderate and irre'ular contractions dilation up to 8 cm brownish:to:pale pink mucus and duration of = to @ hours. "o official Dlull phase e6ists in the first sta'e. he transition phase is characteried by stron' to ery stron' and re'ular contractions @ to 10 cm dilation and duration of 50 to /0 minutes. ,-F# o'nitie +eel# nderstand R$F# p. /8= 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 1=. Which information re'ardin' the procedures and criteria for admittin' a woman to
the hospital labor unit is important for the nurse to understand?
a.
lient is considered to be in actie labor when she arries at the facility with contractions.
b. lient can hae only her male partner or predesi'nated doula with her
at assessment.
c.
hildren are not allowed on the labor unit.
d. "onJ$n'lish speakin' client must brin' someone to translate.
A"!# A
Accordin' to the $mer'ency 4edical reatment and Actie +abor Act ($4A+A) a woman is entitled to actie labor care and is presumed to be in true labor until a 9ualified health care proider certifies otherwise. A woman may hae anyone she wishes present for her support. An interpreter must be proided by the hospital either in person or by a telephonic serice. !iblin's of the new infant may be allowed at the deliery dependin' on hospital policy and ade9uate preparation and superision. ,-F# o'nitie +eel# nderstand R$F# p. /85 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 1>. Which component of the physical e6amination are +eopold%s maneuers unable to
determine?
a.
Bender of the fetus
b. "umber of fetuses
c.
Fetal lie and attitude
d. ,e'ree of the presentin' part%s descent into the pelis
A"!# A
+eopold%s maneuers help identify the number of fetuses the fetal lie and attitude and the de'ree of descent of the presentin' part into the pelis. he 'ender of the fetus cannot be determined by performin' +eopold%s maneuers. ,-F# o'nitie +eel# Remember R$F# pp. /87 //0 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 1@. Where is the point of ma6imal intensity (34-) of the FHR located?
a.
sually directly oer the fetal abdomen
b. -n a erte6 position heard aboe the mother%s umbilicus
c.
Heard lower and closer to the midline of the mother%s abdomen as the fetus descends and internally rotates
d. -n a breech position heard below the mother%s umbilicus
A"!#
"urses should be prepared for the shift. he 34- of the FHR is usually directly oer the fetal back. -n a erte6 position the 34- of the FHR is heard below the mother%s umbilicus. -n a breech position it is heard aboe the mother%s umbilicus. ,-F# o'nitie +eel# nderstand R$F# p. //0 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 17. he nurse should be aware of which information related to a woman%s intake and
output durin' labor?
a.
raditionally restrictin' the laborin' woman to clear li9uids and ice chips is bein' challen'ed because re'ional anesthesia is used more often than 'eneral anesthesia.
b. -ntraenous (-*) fluids are usually necessary to ensure that the laborin'
woman stays hydrated.
c.
Routine use of an enema empties the rectum and is ery helpful for
producin' a clean clear deliery.
d. When a nulliparous woman e6periences the ur'e to defecate it often
means birth will 9uickly follow.
A"!# A
Women are awake with re'ional anesthesia and are able to protect their own airway which reduces the worry oer aspiration. Routine -* fluids durin' labor are unlikely to be beneficial and may be harmful. he routine use of an enema is at best ineffectie and may be harmful. Hain' the ur'e to defecate followed by the birth of her fetus is true for a multiparous woman but not for a nulliparous woman. ,-F# o'nitie +eel# nderstand R$F# p. //< 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 50. Which techni9ue is an ade9uate means of controllin' the birth of the fetal head
durin' deliery in a erte6 presentation?
a.
Rit'en maneuer
b. Fundal pressure
c.
+ithotomy position
d. ,e +ee apparatus
A"!# A
he Rit'en maneuer e6tends the head durin' the actual birth and protects the perineum. Bentle steady pressure a'ainst the fundus of the uterus facilitates a'inal
birth. he lithotomy position has been commonly used in Western cultures partly because it is conenient for the health care proider. he ,e +ee apparatus is used to suction fluid from the infant%s mouth. ,-F# o'nitie +eel# Remember R$F# p. /=/ 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 51. Which collection of risk factors will most likely result in dama'in' lacerations
includin' episiotomies?
a.
,ark:skinned woman who has had more than one pre'nancy who is 'oin' throu'h prolon'ed second:sta'e labor and who is attended by a midwife
b. Reddish:haired mother of two who is 'oin' throu'h a breech birth
c.
,ark:skinned first:time mother who is 'oin' throu'h a lon' labor
d. First:time mother with reddish hair whose rapid labor was oerseen by
an obstetrician
A"!# ,
Reddish:haired women hae tissue that is less distensible than darker:skinned women and therefore may hae less efficient healin'. First:time mothers are also at 'reater risk especially with breech births lon' second:sta'e labors or rapid labors durin' which the time for the perineum to stretch is insufficient. he rate of episiotomies is hi'her when obstetricians rather than midwies attend the births. he woman in the first scenario (a) is at low risk for either dama'in' lacerations or an episiotomy. !he is multiparous has dark skin and is bein' attended by a midwife who is less likely to perform an episiotomy. Reddish:haired women hae tissue that is less distensible than that of darker:skinned women. onse9uently the client in the second scenario (b) is at increased risk for lacerations& howeer she has had two preious delieries which result in a lower likelihood of an episiotomy. he fact that the woman in the third
scenario (c) is e6periencin' a prolon'ed labor mi'ht increase her risk for lacerations. Fortunately she is dark skinned which indicates that her tissue is more distensible than that of fair:skinned women and therefore less susceptible to inEury. ,-F# o'nitie +eel# Apply R$F# p. /=< 23# "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# 3hysiolo'ic -nte'rity 55. Which statement concernin' the third sta'e of labor is correct ?
a.
he placenta eentually detaches itself from a flaccid uterus.
b. An e6pectant or actie approach to mana'in' this sta'e of labor reduces
the risk of complications.
c.
-t is important that the dark rou'hened maternal surface of the placenta appears before the shiny fetal surface.
d. he maEor risk for women durin' the third sta'e is a rapid heart rate.
A"!# ;
Actie mana'ement facilitates placental separation and e6pulsion reducin' the risk of complications. he placenta cannot detach itself from a flaccid (rela6ed) uterus. Which surface of the placenta comes out first is not clinically important. he maEor risk for women durin' the third sta'e of labor is postpartum hemorrha'in'. ,-F# o'nitie +eel# nderstand R$F# p. /== 23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 58. A 5<:year:old 'raida 8 para 5 client 'ae birth to a 7:pound >:ounce boy /
hours a'o after au'mentation of labor with o6ytocin (3itocin). !he presses her call
li'ht and asks for her nurse ri'ht away statin' D-%m bleedin' a lot. What is the most likely cause of postpartum hemorrha'in' in this client?
a.
Retained placental fra'ments
b. nrepaired a'inal lacerations
c.
terine atony
d. 3uerperal infection
A"!#
his woman 'ae birth to a macrosomic infant after o6ytocin au'mentation. ombined with these risk factors uterine atony is the most likely cause of bleedin' / hours after deliery. Althou'h retained placental fra'ments may cause postpartum hemorrha'in' it is typically detected within the first hour after deliery of the placenta and is not the most likely cause of the hemorrha'in' in this woman. Althou'h unrepaired a'inal lacerations may also cause bleedin' it typically occurs in the period immediately after birth. 3uerperal infection can cause subinolution and subse9uent bleedin' that is howeer typically detected 5/ hours postpartum. ,-F# o'nitie +eel# Analye R$F# p. /== 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 5/. -n recoery if a woman is asked to either raise her le's (knees e6tended) off the
bed or fle6 her knees and then place her feet flat on the bed and raise her buttocks well off the bed the purpose of this e6ercise is to assess what?
a.
Recoery from epidural or spinal anesthesia
b. Hidden bleedin' underneath her
c.
Fle6ibility
d. Whether the woman is a candidate to 'o home after = hours
A"!# A
-f the numb or prickly sensations are 'one from her le's after these moements then she has likely recoered from the epidural or spinal anesthesia. Assessin' the client for bleedin' beneath her buttocks before dischar'e from the recoery is always important& howeer she should be rolled to her side for this assessment. he nurse is not re9uired to assess the woman for fle6ibility. his assessment is performed to ealuate whether the client has recoered from spinal anesthesia not to determine if she is a candidate for early dischar'e. ,-F# o'nitie +eel# nderstand R$F# p. /=@ 23# "ursin' 3rocess# $aluation 4!# lient "eeds# 3hysiolo'ic -nte'rity Reduction of Risk 3oten tial 5<. A woman who has a history of se6ual abuse may hae a number of traumatic
memories tri''ered durin' labor. !he may fi'ht the labor process and react with pain or an'er. he nurse can implement a number of care measures to help her client iew the childbirth e6perience in a positie manner. Which interention is key for the nurse to use while proidin' care?
a.
ell the client to rela6 and that it won%t hurt much.
b. +imit the number of procedures that inade her body.
c.
Reassure the client that as the nurse you know what is best.
d. Allow unlimited care proiders to be with the client.
A"!# ;
he number of inasie procedures such as a'inal e6aminations internal monitorin' and -* therapy should be limited as much as possible. he nurse should always aoid words and phrases that may result in the client%s recallin' the phrases of her abuser (i.e. DRela6 this won%t hurt or DLust open your le's). he woman%s sense of control should be maintained at all times. he nurse should e6plain procedures at the client%s pace and wait for permission to proceed. 3rotectin' the client%s enironment by proidin' priacy and limitin' the number of staff who obsere the client will help to make her feel safe. ,-F# o'nitie +eel# nderstand R$F# p. /8< 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3sychosocial -nte'rity 5=. As the nited !tates and anada continue to become more culturally dierse
reco'niin' a wide ran'e of aryin' cultural beliefs and practices is increasin'ly important for the nursin' staff. A client is from which country if she re9uests to hae the baby%s father in attendance?
a.
4e6ico
b. hina
c.
-ran
d. -ndia
A"!# A
Hispanic women routinely hae fathers and female relaties in attendance durin' the second sta'e of labor. he father of the baby is e6pected to proide en coura'ement support and reassurance that all will be well. -n hina fathers are usually not present. he side:lyin' position is preferred for labor and birth because it is belieed that this will reduce trauma to the infant. -n hina the client has a stoic response to pain. -n -ran the father will not be present. Female support persons and female health care proiders are preferred. For many a male care'ier is unacceptable. -n -ndia the father is usually not present but female relaties are usually in attendance. "atural childbirth methods are preferred. ,-F# o'nitie +eel# Apply R$F# p. /8> 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3sychosocial -nte'rity 5>. he *alsala maneuer can be described as the process of makin' a forceful
bearin':down attempt while holdin' one%s breath with a closed 'lottis and a ti'htenin' of the abdominal muscles. When is it appropriate to instruct the client to use this maneuer?
a.
,urin' the second sta'e to enhance the moement of the fetus
b. ,urin' the third sta'e to help e6pel the placenta
c.
,urin' the fourth sta'e to e6pel blood clots
d. "ot at all
A"!# ,
he client should not be instructed to use this maneuer. his process stimulates the parasympathetic diision of the autonomic nerous system and produces a a'al response (decrease in heart rate and blood pressure.) An alternatie method includes instructin' the client to perform open:mouth and open:'lottis breathin' and pushin'. ,-F# o'nitie +eel# Apply R$F# p. /<@
23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic and 3sycholo'ic -nte'rity 5@. he first 1 to 5 hours after birth is sometimes referred to as what?
a.
;ondin' period
b. hird sta'e of labor
c.
Fourth sta'e of labor
d. $arly postpartum period
A"!#
he first 5 hours of the birth are a critical time for the mother and her baby and is often called the fourth stage of labor . 4aternal or'ans under'o their initial readEustment to a nonpre'nant state. he third sta'e of labor lasts from the birth of the baby to the e6pulsion of the placenta. ;ondin' will occur oer a much lon'er period althou'h it may be initiated durin' the fourth sta'e of labor. ,-F# o'nitie +eel# nderstand R$F# p. /=@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 57. When mana'in' the care of a woman in the second sta'e of labor the nurse uses
arious measures to enhance the pro'ress of fetal descent. Which instruction best describes these measures?
a.
$ncoura'in' the woman to try arious upri'ht positions includin' s9uattin' and standin'
b. ellin' the woman to start pushin' as soon as her ceri6 is fully dilated
c.
ontinuin' an epidural anesthetic so pain is reduced and the wo man can rela6
d. oachin' the woman to use sustained 10: to 1<:second closed:'lottis
bearin':down efforts with each contraction
A"!# A
;oth upri'ht and s9uattin' positions may enhance the pro'ress of fetal descent. 4any factors dictate when a woman should be'in pushin'. omplete cerical dilation is necessary but complete dilation is only one factor. -f the fetal head is still in a hi'her pelic station then the physician or midwife may allow the woman to Dlabor down if the woman is able (allowin' more time for fetal descent and thereby reducin' the amount of pushin' needed). he epidural may mask the sensations and muscle control needed for the woman to push effectiely. losed 'lottic breathin' may tri''er the *alsala maneuer which increases intrathoracic and cardioascular pressures reducin' cardiac output and inhibitin' perfusion of the uterus and placenta. -n addition holdin' her breath for lon'er than < to > seconds diminishes the perfusion of o6y'en across the placenta and results in fetal hypo6ia. ,-F# o'nitie +eel# omprehend R$F# p. //7 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 80. When assessin' a multiparous woman who has Eust 'ien birth to an @:pound boy
the nurse notes that the woman%s fundus is firm and has become 'lobular in shape. A 'ush of dark red blood comes from her a'ina. What is the nurse%s assessment of the situation?
a.
he placenta has separated.
b. A cerical tear occurred durin' the birth.
c.
he woman is be'innin' to hemorrha'e.
d. lots hae formed in the upper uterine se'ment.
A"!# A
3lacental separation is indicated by a firmly contractin' uterus a chan'e in the uterus from a discoid to a 'lobular ooid shape a sudden 'ush of dark red blood from the introitus an apparent len'thenin' of the umbilical cord and a findin' of a'inal fullness. erical tears that do not e6tend to the a'ina result in minimal blood loss. !i'ns of hemorrha'e are a bo''y uterus bri'ht red a'inal bleedin' alterations in ital si'ns pallor li'htheadedness restlessness decreased urinary output and alteration in the leel of consciousness. -f clots hae formed in the upper uterine se'ment then the nurse would e6pect to find the uterus bo''y and displaced to the side. ,-F# o'nitie +eel# nderstand R$F# p. /=> 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# Health 3romotion and 4aintenance 81. After an emer'ency birth the nurse encoura'es the woman to breastfeed her
newborn. What is the primary purpose of this actiity?
a.
o facilitate maternal:newborn interaction
b. o stimulate the uterus to contract
c.
o preent neonatal hypo'lycemia
d. o initiate the lactation cycle
A"!# ;
!timulation of the nipples throu'h breastfeedin' or manual stimulation causes the release of o6ytocin and preents maternal hemorrha'e. ;reastfeedin' facilitates maternal:newborn interaction but it is not the primary reason a woman is encoura'ed to breastfeed after an emer'ency birth. he primary interention for preentin' neonatal hypo'lycemia is thermore'ulation. old stress can result in hypo'lycemia. he woman is encoura'ed to breastfeed after an emer'ency birth to stimulate the release of o6ytocin which preents hemorrha'in'. ;reastfeedin' is encoura'ed to initiate the lactation cycle but it is not the primary reason for this actiity after an emer'ency birth. ,-F# o'nitie +eel# nderstand R$F# p. /=7 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 85. A woman who is 87 weeks pre'nant e6presses fear about her impendin' labor and
how she will mana'e. What is the nurse%s ideal response?
a.
D,on%t worry about it. Gou%ll do fine.
b. D-t%s normal to be an6ious about labor. +et%s discuss what makes you
afraid.
c.
D+abor is scary to think about but the actual e6perience isn%t.
d. DGou can hae an epidural. Gou won%t feel anythin'.
A"!# ;
D-t%s normal to be an6ious about labor. +et%s discuss what makes you afraid is a
statement that allows the woman to share her concerns with the nurse and is a therapeutic communication tool. D,on%t worry about it. Gou%ll do fine ne'ates the woman%s fears and is not therapeutic. D+abor is scary to think about but the actual e6perience isn%t ne'ates the woman%s fears and offers a false sense of security. o su''est that eery woman can hae an epidural is untrue. A number of criteria must be met before an epidural is considered. Furthermore many women still e6perience the feelin' of pressure with an epidural. ,-F# o'nitie +eel# Apply R$F# p. /8< 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3sychosocial -nte'rity 88. Which characteristic of a uterine contraction is not routinely documented?
a.
Fre9uency# how often contractions occur
b. -ntensity# stren'th of the contraction at its peak
c.
Restin' tone# tension in the uterine muscle
d. Appearance# shape and hei'ht
A"!# ,
terine contractions are described in terms of fre9uency intensity duration and restin' tone. Appearance is not routinely charted. ,-F# o'nitie +eel# Remember R$F# p. //0 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 8/. nder which circumstance would it be unnecessary for the nurse to perform a
a'inal e6amination?
a.
Admission to the hospital at the start of labor
b. When accelerations of the FHR are noted
c.
2n maternal perception of perineal pressure or the ur'e to bear down
d. When membranes rupture
A"!# ;
An accelerated FHR is a positie si'n& therefore a a'inal e6amination would not be necessary. A a'inal e6amination should be performed when the woman is admitted to the hospital when she perceies perineal pressure or the ur'e to bear down when her membranes rupture when a si'nificant chan'e in her uterine actiity has occurred or when ariable decelerations of the FHR are noted. ,-F# o'nitie +eel# Remember R$F# p. //5 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 8<. Which description of the phases of the second sta'e of labor is most accurate?
a.
+atent phase# Feelin' sleepy& fetal station 5M to /M& duration of 80 to /< minutes
b. Actie phase# 2erwhelmin'ly stron' contractions& Fer'uson reflu6
actiated& duration of < to 1< minutes
c.
,escent phase# !i'nificant increase in contractions& Fer'uson reflu6 actiated& aera'e duration aries
d. ransitional phase# Woman Dlaborin' down& fetal station 0& duration of
1< minutes
A"!#
he descent phase be'ins with a si'nificant increase in contractions& the Fer'uson refle6 is actiated and the duration aries dependin' on a number of factors. he latent phase is the lull or Dlaborin' down period at the be'innin' of the second sta'e and lasts 10 to 80 minutes on aera'e. he second sta'e of labor has no actie phase. he transition phase is the final phase in the second sta'e of labor& contractions are stron' and painful. ,-F# o'nitie +eel# nderstand R$F# p. /
important nursin' assessment at this time?
a.
ontraction pattern amount of discomfort and pre'nancy history
b. FHR maternal ital si'ns and the woman%s nearness to birth
c.
-dentification of ruptured membranes woman%s 'raida and para and her support person
d. +ast food intake when labor be'an and cultural practices the couple
desires
A"!# ;
All options describe releant intrapartum nursin' assessments& howeer this focused assessment has a priority. -f the maternal and fetal conditions are normal and birth is
not imminent then other assessments can be performed in an unhurried manner& these include# 'raida para support person pre'nancy history pain assessment last food intake and cultural practices. ,-F# o'nitie +eel# Apply R$F# p. /=0 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 8>. A primi'raida at 87 weeks of 'estation is obsered for 5 hours in the intrapartum
unit. he FHR has been normal. ontractions are < to 7 minutes apart 50 to 80 seconds in duration and of mild intensity. erical dilation is 1 to 5 cm and uneffaced (unchan'ed from admission). 4embranes are intact. What disposition would the nurse anticipate?
a.
Admitted and prepared for a cesarean birth
b. Admitted for e6tended obseration
c.
,ischar'ed home with a sedatie
d. ,ischar'ed home to await the onset of true labor
A"!# ,
his situation describes a woman with normal assessments who is probably in false labor and will likely not delier rapidly once true labor be'ins. "o further assessments or obserations are indicated& therefore the client will be dischar'ed alon' with instructions to return when contractions increase in intensity and fre9uency. "either a cesarean birth nor a sedatie is re9uired at this time. ,-F# o'nitie +eel# Analye R$F# p. /81 23# "ursin' 3rocess# Assessment 4!# lient "eeds# !afe and $ffectie are $nironment
8@. A laborin' woman is reclinin' in the supine position. What is the most appropriate
nursin' action at this time?
a.
Ask her to turn to one side.
b. $leate her feet and le's.
c.
ake her blood pressure.
d. ,etermine whether fetal tachycardia is present.
A"!# A
he woman%s supine position may cause the heay uterus to compress her inferior ena caa thus reducin' blood return to her heart and reducin' placental blood flow. $leatin' her le's will not reliee the pressure from the inferior ena caa. -f the woman is allowed to stay in the supine position and blood flow to the placental is reduced si'nificantly then fetal tachycardia may occur. he most appropriate nursin' action is to preent this from occurrin' by turnin' the woman to her side. ;lood pressure readin's may be obtained when the client is in the appropriate and safest position. ,-F# o'nitie +eel# Apply R$F# p. /87 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 87. Which nursin' assessment indicates that a woman who is in second:sta'e labor is
almost ready to 'ie birth?
a.
Fetal head is felt at 0 station durin' a'inal e6amination.
b. ;loody mucous dischar'e increases.
c.
*ula bul'es and encircles the fetal head.
d. 4embranes rupture durin' a contraction.
A"!#
A bul'in' ula that encircles the fetal head describes crownin' which occurs shortly before birth. ;irth of the head occurs when the station is M/. A 0 station indicates en'a'ement. ;loody show occurs throu'hout the labor process and is not an indication of an imminent birth. R24 can occur at any time durin' the labor process and does not indicate an imminent birth. ,-F# o'nitie +eel# Analye R$F# p. /<= 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance /0. What is the primary rationale for the thorou'h dryin' of the infant immediately
after birth?
a.
!timulates cryin' and lun' e6pansion
b. Remoes maternal blood from the skin surface
c.
Reduces heat loss from eaporation
d. -ncreases blood supply to the hands and feet
A"!#
-nfants are wet with amniotic fluid and blood at birth and this accelerates eaporatie heat loss. he primary purpose of dryin' the infant is to preent heat loss. Althou'h rubbin' the infant stimulates cryin' it is not the main reason for dryin' the infant. his process does not remoe all the maternal blood. ,-F# o'nitie +eel# nderstand R$F# p. /<> 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity M$L%'L# )#*'(+*#
1. $mer'ency conditions durin' labor that would re9uire immediate nursin'
interention can arise with startlin' speed. Which situations are e6amples of such an emer'ency? (Select all that apply.)
a. "onreassurin' or abnormal FHR pattern
b. -nade9uate uterine rela6ation
c.
*a'inal bleedin'
d. 3rolon'ed second sta'e
e.
3rolapse of the cord
A"!# A ; $
A nonreassurin' or abnormal FHR pattern inade9uate uterine rela6ation a'inal bleedin' infection and cord prolapse all constitute an emer'ency durin' labor that re9uires immediate nursin' interention. A prolon'ed second sta'e of labor after the upper limits for duration is reached. his is 8 hours for nulliparous women and 5 hours for multiparous women. ,-F# o'nitie +eel# nderstand R$F# pp. /<8:/
23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# 3hysiolo'ic -nte'rity 5. Women who hae participated in childbirth education classes often brin' a birth
plan with them to the hospital. Which items mi'ht this plan include? (Select all that apply.)
a.
3resence of companions
b. lothin' to be worn
c.
are and handlin' of the newborn
d. 4edical interentions
e.
,ate of deliery
A"!# A ; ,
he presence of companions clothin' to be worn care and handlin' of the newborn medical interentions and enironmental modifications all mi'ht be included in the couple%s birth plan. 2ther items include the presence of nonessential medical personnel (students) labor actiities such as the tub or ambulation preferred comfort and rela6ation methods and any cultural or reli'ious re9uirements. he e6pected date of deliery would not be part of a birth plan unless the client is scheduled for an electie cesarean birth. ,-F# o'nitie +eel# Apply R$F# p. /8< 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic and 3sycholo'ic -nte'rity MA%C!+,
he a'inal e6amination is an essential component of labor assessment. -t reeals whether the client is in true labor and enables the e6aminer to determine whether membranes hae ruptured. he a'inal e6amination is often stressful and uncomfortable for the client and should be performed only when indicated. 4atch the correct step number from 1 to > with each component of a a'inal e6amination of the laborin' woman.
a.
After obtainin' permission 'ently insert the inde6 and middle fin'ers into the a'ina.
b. $6plain the findin's to the client.
c.
3osition the woman to preent supine hypotension.
d. se sterile 'loes and soluble 'el for lubrication.
e.
,ocument findin's and report to the health care proider.
f.
leanse the perineum and ula if necessary.
'. ,etermine dilation presentin' part status of membranes and
characteristics of amniotic fluid.
1. !tep 1 5. !tep 5 8. !tep 8 /. !tep /
<. !tep < =. !tep = >. !tep > 1. A"!# , ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort. 5. A"!# ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort. 8. A"!# F ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort. /. A"!# A ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort.
<. A"!# B ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort. =. A"!# ; ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort. >. A"!# $ ,-F# o'nitie +eel# Apply R$F# p. /// 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity "2# he a'inal e6amination should be performed on admission before administerin' anal'esics when a si'nificant chan'e in uterine actiity has occurred on maternal perception of perineal pressure when membranes rupture or when the nurse notes ariable decelerations of the FHR. A full e6planation of the e6amination and support of the woman are important in reducin' the leel of stress and discomfort.
Chapter 0: 'ostpartum 'hysiologi2 Changes Lowdermilk: Maternity & Womens !ealth Care" 11th #dition M$L%'L# C!(C#
1. A woman 'ae birth to an infant boy 10 hours a'o. Where does the nurse e6pect to
locate this woman%s fundus?
a.
1 centimeter aboe the umbilicus
b. 5 centimeters below the umbilicus
c.
4idway between the umbilicus and the symphysis pubis
d. "onpalpable abdominally
A"!# A
he fundus descends appro6imately 1 to 5 cm eery 5/ hours. Within 15 hours after deliery the fundus may be appro6imately 1 cm aboe the umbilicus. ;y the si6th postpartum week the fundus is normally halfway between the symphysis pubis and the umbilicus. he fundus should be easily palpated usin' the maternal umbilicus as a reference point. ,-F# o'nitie +eel# nderstand R$F# p. />8 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 5. What are the most common causes for subinolution of the uterus?
a.
3ostpartum hemorrha'e and infection
b. 4ultiple 'estation and postpartum hemorrha'e
c.
terine tetany and oerproduction of o6ytocin
d. Retained placental fra'ments and infection
A"!# ,
!ubinolution is the failure of the uterus to return to a nonpre'nant state. he most common causes of subinolution are retained placental fra'ments and infection. !ubinolution may be caused by an infection and result in hemorrha'e. 4ultiple 'estations may cause uterine atony resultin' in postpartum hemorrha'in'. terine tetany and oerproduction of o6ytocin do not cause subinolution. ,-F# o'nitie +eel# nderstand R$F# p. />8 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 8. Which client is most likely to e6perience stron' and uncomfortable afterpains?
a.
A woman who e6perienced oli'ohydramnios
b. A woman who is a 'raida / para /:0:0:/
c.
A woman who is bottle:feedin' her infant
d. A woman whose infant wei'hed < pounds 8 ounces
A"!# ;
Afterpains are more common in multiparous women. -n a woman who e6perienced polyhydramnios afterpains are more noticeable because the uterus was 'reatly distended. ;reastfeedin' may cause the afterpains to intensify. -n a woman who deliered a lar'e infant afterpains are more noticeable because the uterus was 'reatly distended. ,-F# o'nitie +eel# nderstand R$F# p. />/ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance /. A woman 'ae birth to a healthy infant boy < days a'o. What type of lochia does
the nurse e6pect to find when ealuatin' this client?
a.
+ochia rubra
b. +ochia san'ra
c.
+ochia alba
d. +ochia serosa
A"!# ,
+ochia serosa which consists of blood serum leukocytes and tissue debris 'enerally occurs around day 8 or / after childbirth. +ochia rubra consists of blood and decidual and trophoblastic debris. he flow 'enerally lasts 8 to / days a nd pales becomin' pink or brown. +ochia san'ra is not a real term. +ochia alba occurs in most women after day 10 and can continue up to = weeks after childbirth. ,-F# o'nitie +eel# nderstand R$F# p. />/ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance <. Which hormone remains eleated in the immediate postpartum period of the
breastfeedin' woman?
a.
$stro'en
b. 3ro'esterone
c.
3rolactin
d. Human placental lacto'en
A"!#
3rolactin leels in the blood pro'ressiely increase throu'hout pre'nancy. -n women who breastfeed prolactin leels remain eleated into the si6th week after birth. $stro'en leels decrease si'nificantly after e6pulsion of the placenta reachin' their lowest leels 1 week into the postpartum period. 3ro'esterone leels decrease si'nificantly after e6pulsion of the placenta reachin' their lowest leels 1 week into the postpartum period. Human placental lacto'en leels dramatically decrease after e6pulsion of the placenta. ,-F# o'nitie +eel# Remember R$F# p. />= 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance =. wo days a'o a woman 'ae birth to a full:term infant. +ast ni'ht she awakened
seeral times to urinate and noted that her 'own and beddin' were wet from profuse diaphoresis. Which physiolo'ic alteration is the cause for the diaphoresis and diuresis that this client is e6periencin'?
a.
$leated temperature caused by postpartum infection
b. -ncreased basal metabolic rate after 'iin' birth
c.
+oss of increased blood olume associated with pre'nancy
d. -ncreased enous pressure in the lower e6tremities
A"!#
Within 15 hours of birth women be'in to lose the e6cess tissue fluid that has accumulated durin' pre'nancy. 2ne mechanism for reducin' these retained fluids is
the profuse diaphoresis that often occurs especially at ni'ht for the first 5 or 8 days after childbirth. 3ostpartal diuresis is another mechanism by which the body rids itself of e6cess fluid. An eleated temperature causes chills and possibly dehydration not diaphoresis and diuresis. ,iaphoresis and diuresis are sometimes referred to as reersal of the water metabolism of pre'nancy not as the basal metabolic rate. 3ostpartal diuresis may be caused by the remoal of increased enous pressure in the lower e6tremities. ,-F# o'nitie +eel# nderstand R$F# p. />= 23# "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# 3hysiolo'ic -nte'rity >. Which term best describes the interal between the birth of the newborn and the
return of the reproductie or'ans to their normal nonpre'nant state?
a.
-nolutionary period because of what happens to the uterus
b. +ochia period because of the nature of the a'inal dischar'e
c.
4ini:tri period because it lasts only 8 to = weeks
d. 3uerperium or fourth trimester of pre'nancy
A"!# ,
he puerperium also called the fourth trimester or the postpartum period of pregnancy is the final period of pre'nancy and lasts appro6imately 8 to = weeks. -nolution marks the end of the puerperium. +ochia refers to the arious a'inal dischar'es durin' the puerperium. ,-F# o'nitie +eel# Remember R$F# p. />8 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance
@. A woman 'ae birth to a >:pound =:ounce infant 'irl 1 hour a'o. he birth was
a'inal and the estimated blood loss ($;+) was 1<00 ml. When ealuatin' the woman%s ital si'ns which findin' would be of 'reatest concern to the nurse?
a.
emperature 8>.7N heart rate 150 beats per minute (bpm) respirations 50 breaths per minute and blood pressure 70<0 mm H'
b. emperature 8>./N heart rate @@ bpm respirations 8= breaths per
minute and blood pressure 15==@ mm H'
c.
emperature 8@N heart rate @0 bpm respirations 1= breaths per minute and blood pressure 110@0 mm H'
d. emperature 8=.@N heart rate =0 bpm respirations 1@ breaths per
minute and blood pressure 1/070 mm H'
A"!# A
An $;+ of 1<00 ml with tachycardia and hypotension su''ests hypoolemia caused by e6cessie blood loss. emperature 8>./N heart rate @@ bpm respirations 8= breaths per minute and blood pressure 15==@ mm H' are normal ital si'ns e6cept for an increased respiratory rate which may be secondary to pain from the birth. emperature 8@N heart rate @0 bpm respirations 1= breaths per minute and blood pressure 110@0 mm H' are normal ital si'ns e6cept for the temperature which may increase to 8@N durin' the first 5/ hours as a result of the dehydratin' effects of labor. emperature 8=.@N heart rate =0 bpm respirations 1@ breaths per minute and blood pressure 1/070 mm H' are normal ital si'ns althou'h the blood pressure is sli'htly eleated which may be attributable to the use of o6ytocic medications. ,-F# o'nitie +eel# Analye R$F# pp. />> />@ 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# ,ia'nosis 4!# lient "eeds# 3hysiolo'ic -nte'rity
7. A client is concerned that her breasts are en'or'ed and uncomfortable. What is the
nurse%s e6planation for this physiolo'ic chan'e?
a.
2erproduction of colostrum
b. Accumulation of milk in the lactiferous ducts and 'lands
c.
Hyperplasia of mammary tissue
d. on'estion of eins and lymphatic essels
A"!# ,
;reast en'or'ement is caused by the temporary con'estion of eins and lymphatic essels. An oerproduction of colostrum an accumulation of milk in the lactiferous ducts and 'lands and hyperplasia of mammary tissue do not cause breast en'or'ement. ,-F# o'nitie +eel# Apply R$F# p. />> 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 10. After deliery e6cess hypertrophied tissue in the uterus under'oes a period of self:
destruction. What is the correct term for this process?
a.
Autolysis
b. !ubinolution
c.
Afterpains
d. ,iastasis
A"!# A
Autolysis is caused by a decrease in hormone leels. Subinvolution is failure of the uterus to return to a nonpre'nant state. Afterpains are caused by uterine cramps 5 to 8 days after birth. Diastasis refers to the separation of muscles. ,-F# o'nitie +eel# Remember R$F# p. />8 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 11. Which statement re'ardin' the postpartum uterus is correct ?
a.
At the end of the third sta'e of labor the postpartum uterus wei'hs appro6imately <00 '.
b. After 5 weeks postpartum it should be abdominally nonpalpable.
c.
After 5 weeks postpartum it wei'hs 100 '.
d. 3ostpartum uterus returns to its ori'inal (prepre'nancy) sie by = weeks
postpartum.
A"!# ;
he uterus does not return to its ori'inal sie. At the end of the third sta'e of labor the uterus wei'hs appro6imately 1000 '. After 5 weeks postpartum the uterus wei'hs appro6imately 8<0 '. he normal self:destruction of e6cess hypertrophied tissue accounts for the sli'ht increase in uterine sie after each pre'nancy. ,-F# o'nitie +eel# nderstand R$F# p. />8 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance
15. A client asks the nurse when her oaries will be'in workin' a'ain. Which
e6planation by the nurse is most accurate?
a.
Almost >
b. 2ulation occurs sli'htly earlier for breastfeedin' women.
c.
;ecause of menstruation and oulation schedules contraception considerations can be postponed until after the puerperium.
d. he first menstrual flow after childbirth usually is heaier than normal.
A"!# ,
he first flow is heaier but within three or four cycles the flow is back to normal. 2ulation can occur within the first month but for >0O of nonlactatin' women it returns in appro6imately 8 months. Women who are breastfeedin' take lon'er to resume oulation. ;ecause many women oulate before their first postpartum menstrual period contraceptie options need to be discussed early in the puerperium. ,-F# o'nitie +eel# Apply R$F# p. />= 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity 18. he nurse should be co'niant of which postpartum physiolo'ic alteration?
a.
ardiac output pulse rate and stroke olume all return to prepre'nancy normal alues within a few hours of childbirth.
b. Respiratory function returns to nonpre'nant leels by = to @ weeks after
childbirth.
c.
+owered white blood cell count after pre'nancy can lead to false: positie results on tests for infections.
d. Hypercoa'ulable state protects the new mother from thromboembolism
especially after a cesarean birth.
A"!# ;
Respirations should decrease to within the woman%s normal prepre'nancy ran'e by = to @ weeks after childbirth. !troke olume increases and cardiac output remains hi'h for a couple of days. Howeer the heart rate and blood pressure 9uickly return to normal. +eukocytosis increases 10 to 15 days after childbirth which can obscure the dia'nosis of acute infections producin' false:ne'atie test results. he hypercoa'ulable state increases the risk of thromboembolism especially after a cesarean birth. ,-F# o'nitie +eel# nderstand R$F# p. />@ 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity 1/. Which condition not uncommon in pre'nancy is likely to re9uire careful medical
assessment durin' the puerperium?
a.
*aricosities of the le's
b. arpal tunnel syndrome
c.
3eriodic numbness and tin'lin' of the fin'ers
d. Headaches
A"!# ,
Headaches in the postpartum period can hae a number of causes some of which desere medical attention. otal or nearly total re'ression of aricosities is e6pected after childbirth. arpal tunnel syndrome is relieed in childbirth when the compression on the median nere is lessened. 3eriodic numbness of the fin'ers usually disappears after childbirth unless carryin' the baby a''raates the condition. ,-F# o'nitie +eel# nderstand R$F# p. />7 23# "ursin' 3rocess# $aluation 4!# lient "eeds# 3hysiolo'ic -nte'rity 1<. !eeral deliery chan'es in the inte'umentary system that appear durin'
pre'nancy disappear after birth althou'h not always completely. What chan'e is almost certain to be completely reersed?
a. "ail brittleness
b. ,arker pi'mentation of the areolae and linea ni'ra
c.
!triae 'raidarum on the breasts abdomen and thi'hs
d. !pider nei
A"!# A
he nails return to their prepre'nancy consistency and stren'th. !ome women hae permanent darker pi'mentation of the areolae and linea ni'ra. !triae 'raidarum (stretch marks) usually do not completely disappear. For some women spider nei persist indefinitely.
,-F# o'nitie +eel# nderstand R$F# p. /@0 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity 1=. 3elic floor e6ercises also known as Ke'el e6ercises will help to stren'then the
perineal muscles and encoura'e healin' after childbirth. he nurse re9uests the client to repeat back instructions for this e6ercise. Which response by the client indicates successful learnin'?
a.
D- contract my thi'hs buttocks and abdomen.
b. D- perform 10 of these e6ercises eery day.
c.
D- stand while practicin' this new e6ercise routine.
d. D- pretend that - am tryin' to stop the flow of urine in midstream.
A"!# ,
he woman can pretend that she is attemptin' to stop the passin' of 'as or the flow of urine midstream which will replicate the sensation of the muscles drawin' upward and inward. $ach contraction should be as intense as possible without contractin' the abdomen buttocks or thi'hs. Buidelines su''est that these e6ercises should be performed 5/ to 100 times per day. 3ositie results are shown with a minimum of 5/ to /< repetitions per day. he best position to learn Ke'el e6ercises is to lie supine with the knees bent. A secondary position is on the hands and knees. ,-F# o'nitie +eel# Analye R$F# p. />< 23# "ursin' 3rocess# $aluation 4!# lient "eeds# Health 3romotion and 4aintenance !elf:are 1>. Which statement by a newly deliered woman indicates that she knows what to
e6pect re'ardin' her menstrual actiity after childbirth?
a.
D4y first menstrual cycle will be li'hter than normal and then will 'et
heaier eery month thereafter.
b. D4y first menstrual cycle will be heaier than normal and will return to
my prepre'nant olume within three or four cycles.
c.
D- will not hae a menstrual cycle for = months after childbirth.
d. D4y first menstrual cycle will be heaier than normal and then will be
li'ht for seeral months after.
A"!# ; D4y first menstrual cycle will be heaier than normal and will return to my
prepre'nant olume within three or four cycles is an accurate statement and indicates her understandin' of her e6pected menstrual actiity. !he can e6pect her first menstrual cycle to be heaier than normal which occurs by 8 months after childbirth and the olume of her subse9uent cycles will return to prepre'nant leels within three to four cycles. ,-F# o'nitie +eel# Apply R$F# p. />= 23# "ursin' 3rocess# $aluation 4!# lient "eeds# Health 3romotion and 4aintenance 1@. he nurse is proidin' instruction to the newly deliered client re'ardin' postbirth
uterine and a'inal dischar'e called lochia. Which statement is the most appropriate?
a.
+ochia is similar to a li'ht menstrual period for the first = to 15 hours.
b. -t is usually 'reater after cesarean births.
c.
+ochia will usually decrease with ambulation and breastfeedin'.
d. -t should smell like normal menstrual flow unless an infection is
present.
A"!# ,
An offensie odor usually indicates an infection. +ochia flow should appro6imate a heay menstrual period for the first 5 hours and then steadily decrease. +ess lochia is usually seen after cesarean births and usually increases with a mbulation and breastfeedin'. ,-F# o'nitie +eel# nderstand R$F# p. />< 23# "ursin' 3rocess# Assessment 4!# lient "eeds# Health 3romotion and 4aintenance 17. Which description of postpartum restoration or healin' times is accurate?
a.
he ceri6 shortens becomes firm and returns to form within a month postpartum.
b. *a'inal ru'ae reappear by 8 weeks postpartum.
c.
4ost episiotomies heal within a week.
d. Hemorrhoids usually decrease in sie within 5 weeks of childbirth.
A"!# ;
*a'inal ru'ae reappear by 8 weeks postpartum& howeer they are neer as prominent as in nulliparous women. he ceri6 re'ains its form within days& the cerical os may
take lon'er. 4ost episiotomies take 5 to 8 weeks to heal. Hemorrhoids can take = weeks to decrease in sie. ,-F# o'nitie +eel# nderstand R$F# p. />< 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# Health 3romotion and 4aintenance 50. Which statement related to the reconditionin' of the urinary system after
childbirth should the nurse understand?
a.
Kidney function returns to normal a few days after birth.
b. ,iastasis recti abdominis is a common condition that alters the oidin'
refle6.
c.
Fluid loss throu'h perspiration and increased urinary output accounts for a wei'ht loss of more than 5 k' durin' the puerperium.
d. With ade9uate emptyin' of the bladder bladder tone is usually restored
5 to 8 weeks after childbirth.
A"!#
$6cess fluid loss throu'h other means besides perspiration and increased urinary output occurs as well. Kidney function usually returns to normal in appro6imately 1 month. ,iastasis recti abdominis is the separation of muscles in the abdominal wall and has no effect on the oidin' refle6. ;ladder tone is usually restored < to > days after childbirth. ,-F# o'nitie +eel# nderstand R$F# p. />= 23# "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity 51. What should the nurse%s ne6t action be if the client%s white blood cell (W;) count
is 5<000mm8 on her second postpartum day?
a.
-mmediately inform the physician.
b. Hae the laboratory draw blood for reanalysis.
c.
Reco'nie that this count is an acceptable ran'e at this point postpartum.
d. -mmediately be'in antibiotic therapy.
A"!#
,urin' the first 10 to 15 days after childbirth W; alues between 50000 and 5<000mm8 are common. ;ecause a W; count of 5<000mm 8 on her second postpartum day is normal alertin' the physician is not warranted nor is reassessment or antibiotics needed& the W; count is not eleated. ,-F# o'nitie +eel# Apply R$F# p. />@ 23# "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 55. Which documentation on a woman%s chart on postpartum day 1/ indicates a
normal inolution process?
a.
4oderate bri'ht red lochial flow
b. ;reasts firm and tender
c.
Fundus below the symphysis and nonpalpable
d. $pisiotomy sli'htly red and puffy
A"!#
he fundus descends 1 cm per day& conse9uently it is no lon'er palpable by postpartum day 1/. he lochia should be chan'ed by this day to serosa. ;reasts are not part of the inolution process. he episiotomy should not be red or puffy at this sta'e. ,-F# o'nitie +eel# Apply R$F# p. />8 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity M$L%'L# )#*'(+*#
1. he breast:feedin' mother should be tau'ht to e6pect which chan'es to the
condition of the breasts? (Select all that apply.)
a.
;reast tenderness is likely to persist for appro6imately 1 week after the start of lactation.
b. As lactation is established a mass may form that can be distin'uished
from cancer by its positional shift from day to day.
c.
-n nonlactatin' mothers colostrum is present for the first few days a fter childbirth.
d. -f sucklin' is neer be'un or is discontinued then lactation ceases
within a few days to a week.
e.
+ittle chan'e occurs to the breasts in the first /@ hours.
A"!# ; ,
;reasts become fuller and heaier as colostrum transitions to milk& this fullness should last >5 to 7= hours. he moable noncancerous mass is a filled milk sac. olostrum is present for a few days whether or not the mother breastfeeds. A mother who does not want to breastfeed should also aoid stimulatin' her nipples. +ittle chan'e to the breasts occurs in the first 5/ hours of childbirth. ,-F# o'nitie +eel# nderstand R$F# p. />> 23# "ursin' 3rocess# 3lannin' C "ursin' 3rocess# -mplementation 4!# lient "eeds# Health 3romotion and 4aintenance 5. han'es in blood olume after childbirth depend on seeral factors such as blood
loss durin' childbirth and the amount of e6traascular water (physiolo'ic edema) mobilied and e6creted. What amount of blood loss does the postpartum nurse anticipate? (Select all that apply.)
a.
100 ml
b. 5<0 ml or less
c.
800 to <00 ml
d. <00 to 1000 ml
e.
1<00 ml or 'reater
A"!# ,
he aera'e blood loss for a a'inal birth of a sin'le fetus ran'es from 800 to <00 ml (10O of blood olume). he typical blood loss for women who 'ae birth by cesarean is <00 to 1000 ml (1
childbirth the plasma olume further decreases as a result of diuresis. 3re'nancy: induced hyperolemia (i.e. an increase in blood olume of at least 8> 23# "ursin' 3rocess# Assessment C "ursin' 3rocess# 3lannin' 4!# lient "eeds# 3hysiolo'ic -nte'rity MA%C!+,
he physiolo'ic chan'es that occur durin' the reersal of the processes of pre'nancy are distinctie& howeer they are normal. o proide care durin' this recoery period the nurse must synthesie knowled'e re'ardin' anticipated maternal chan'es and deiations from normal. 4atch the ital si'ns findin' that the postpartum nurse may encounter with its probable cause.
a.
$leated temperature within the first 5/ hours
b. Rapid pulse
c.
$leated temperature at 8= hours postpartum
d. Hypertension
e.
Hypoentilation
1. 3uerperal sepsis 5. nusually hi'h epidural or spinal block 8. ,ehydratin' effects of labor
/. Hypoolemia resultin' from hemorrha'e <. $6cessie use of o6ytocin 1. A"!# ,-F# o'nitie +eel# omprehend R$F# p. />@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 5. A"!# $ ,-F# o'nitie +eel# omprehend R$F# p. />@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity 8. A"!# A ,-F# o'nitie +eel# omprehend R$F# p. />@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity /. A"!# ; ,-F# o'nitie +eel# omprehend R$F# p. />@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity <. A"!# , ,-F# o'nitie +eel# omprehend R$F# p. />@ 23# "ursin' 3rocess# Assessment 4!# lient "eeds# 3hysiolo'ic -nte'rity Chapter 18
1.-,# 8>70@18>/0 Fetal bradycardia is most common durin'# •
4aternal hyperthyroidism.
•
Fetal anemia.
•
*iral infection. orrect
•
ocolytic treatment usin' ritodrine.
Fetal bradycardia can be considered a later si'n of fetal hypo6ia and is known to occur before fetal death. ;radycardia can result from placental transfer of dru's iral infections such as cytome'aloirus (4*) maternal hypothermia and maternal hypothermia. 4aternal hyperthyroidism fetal anemia and tocolytic treatment usin' ritodrine will most likely result in fetal tachycardia. Awarded 0.0 points out of 1.0 possible points. 5.-,# 8>70@18><1
he nurse proidin' care for the laborin' woman understands that accelerations with fetal moement# •
Are reassurin'. orrect
•
Are caused by umbilical cord compression.
•
Warrant close obseration.
•
Are caused by uteroplacental insufficiency.
$pisodic accelerations in the fetal heart rate (FHR) occur durin' fetal moement and are indications of fetal well:bein'& they do not warrant close obseration. mbilical cord compression results in ariable decelerations in the FHR. teroplacental insufficiency would result in late decelerations in the FHR. Awarded 0.0 points out of 1.0 possible points. 8.-,# 8>70@18>/> he most common cause of decreased ariability in the FHR that lasts 80 minutes or less is# •
Altered cerebral blood flow.
•
Fetal hypo6emia.
•
mbilical cord compression.
•
Fetal sleep cycles. orrect
A temporary decrease in ariability can occur when the fetus is in a sleep state. hese sleep states do not usually last lon'er than 80 minutes. Altered fetal cerebral blood flow results in early decelerations in the FHR and umbilical cord compression in ariable decelerations. Fetal hypo6emia is eidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR ariability may be seen. Awarded 0.0 points out of 1.0 possible points. /.-,# 8>70@18>/7 Gou are ealuatin' the fetal monitor tracin' of your client who is in actie labor. !uddenly you see the fetal heart rate (FHR) drop from its baseline of 15< down to @0. Gou reposition the mother proide o6y'en increase -* fluid and perform a a'inal e6am. he ceri6 has not chan'ed. Fie minutes hae passed and the FHR remains in the @0s. What additional nursin' measures should you take? •
all for help.
•
-nsert a Foley catheter.
•
!tart o6ytocin (3itocin).
•
"otify the primary health care proider immediately. orrect
o reliee an FHR deceleration the nurse can reposition the mother increase -* fluid and proide o6y'en. Also if o6ytocin is bein' infused it should be discontinued. -f the FHR does not resole the primary health care proider should be notified immediately. Althou'h it is always a 'ood idea to hae e6tra help durin' any unanticipated obstetric eent callin' for help is not the most important nursin' measure at this time. -f the FHR were to co ntinue in an abnormal or nonreassurin' pattern a cesarean section mi'ht be warranted. his would re9uire the insertion of a Foley catheter& howeer the physician must make that determination. 26ytocin may put additional stress on the fetus. Awarded 0.0 points out of 1.0 possible points. <.-,# 8>70@18>/< When usin' intermittent auscultation (-A) to assess uterine actiity nurses should be aware that# •
•
•
•
he e6aminer%s hand should be placed oer the fundus before durin' and after contractions. orrect he fre9uency and duration of contractions are measured in seconds for consistency. ontraction intensity is 'ien a Eud'ment number of 1 to > by the nurse and client to'ether. he restin' tone between contractions is described as either p lacid or turbulent.
he assessment is done by palpation& duration fre9uency intensity and restin' tone must be assessed. he duration of contractions is measured in seconds& the fre9uency is measured in minutes. he intensity of contractions usually is described as mild moderate or stron'. he restin' tone usually is characteried as soft or rela6ed. Awarded 0.0 points out of 1.0 possible points. =.-,# 8>70@18>85 A nurse carin' for a woman in labor understands that increased ariability of the fetal h eart rate mi'ht be caused by# •
•
"arcotics. ;arbiturates.
•
4ethamphetamines. orrect
•
ran9uiliers.
he use of illicit dru's such as cocaine or methamphetamines mi'ht cause increased ariability. 4aternal in'estion of narcotics and tran9uilier use may be the causes of decreased ariability. he use of barbiturates may also result in a si'nificant decrease in ariability as these dru's are known to cross the placental barrier. Awarded 0.0 points out of 1.0 possible points. >.-,# 8>70@18><8 Which of the followin' statements is not used to describe a characteristic of a uterine contraction? •
Fre9uency (how often contractions occur)
•
-ntensity (the stren'th of the contraction at its peak)
•
Restin' tone (the tension in the uterine muscle)
•
Appearance (shape and hei'ht) orrect
terine contractions are described in terms of fre9uency intensity duration and restin' tone. Awarded 0.0 points out of 1.0 possible points. @.-,# 8>70@18>8= he nurse carin' for a laborin' woman is aware that maternal cardiac output can be increased by# •
han'e in position. orrect
•
26ytocin administration.
•
Re'ional anesthesia.
•
-ntraenous anal'esic.
4aternal supine hypotension syndrome is caused by the wei'ht and pressure of the 'raid uterus on the ascendin' ena caa when the woman is in a supine position. his pressure reduces enous return to the woman%s heart as well as cardiac output and subse9ue ntly lowers her blood pressure. he nurse can encoura'e the woman to chan'e positions and aoid the supine position. 26ytocin administration re'ional anesthesia and intraenous anal'esic may all reduc e maternal cardiac output. Awarded 0.0 points out of 1.0 possible points.
7.-,# 8>70@18>8@ Fetal well:bein' durin' labor is assessed by# •
he response of the fetal heart rate (FHR) to uterine contractions (s). orrect
•
4aternal pain control.
•
Accelerations in the FHR.
•
An FHR 'reater than 110 beatsmin.
Fetal well:bein' durin' labor can be measured by the response of the FHR to s. -n 'eneral reassurin' FHR patterns are characteried by an FHR baseline in the ran'e of 110 to 1=0 beatsmin with no periodic chan'es a moderate baseline ariability and accelerations with fetal moement. Althou'h FHR accelerations and an FHR 'reater than 110 beatsmin may be reassurin' they are only two components of the criteria by which fetal well:bein' is assessed. 4ore information is needed to determine fetal well:bein'. Awarded 0.0 points out of 1.0 possible points. 10.-,# 8>70@18>8/ A 'roup of fetal monitorin' e6perts ("ational -nstitute of hild Health and Human ,eelopment 500@) recommends that fetal heart rate (FHR) tracin's demonstrate certain characteristics to be described as reassurin' or normal (cate'ory -). hese characteristics include# •
;radycardia not accompanied by baseline ariability.
•
$arly decelerations either present or absent. orrect
•
!inusoidal pattern.
•
achycardia.
$arly decelerations the absence of late decelerations and the presence of accelerations indicate a normal cate'ory - tracin'. ;radycardia not acco mpanied by ariability is a cate'ory -- tracin' as is fetal tachycardia. A sinusoidal pattern is considered an ominous si'n and is definitely an abnormal cate'ory --- tracin'. Awarded 0.0 points out of 1.0 possible points. Chapter 19
*ubmission Details
•
!ubmission ,ate# =<501=
•
!ubmission ime# @#5/ A4
•
3oints Awarded# 0
•
3oints 4issed# 15
•
"umber of Attempts Allowed# nlimited
•
"ot !cored# 0
•
3ercenta'e# 0O
13 4uestions
1. 1.-,# 8>70>@8017 A nurse teaches a pre'nant woman about the ch aracteristics of true labor contractions. he nurse ealuates her understandin' of the instructions when the woman states#
Drue labor contractions will subside when - walk around. Drue labor contractions will cause discomfort oer the top of my uterus. Drue labor contractions will continue and 'et stron'er een if - rela6 and take a shower. orrect Drue labor contractions will remain irre'ular but become stron'er.
rue labor contractions occur re'ularly become stron'er last lon'er and occur closer to'ether. hey may become intense durin' walkin' and continue d espite comfort measures. ypically true labor contractions are felt in the lower back radiatin' to the lower portion of the abdomen. ,urin' false labor contractions tend to be irre'ular and felt in the abdomen aboe the nael. ypically the contractions stop with walkin' or a chan'e of position. Awarded 0.0 points out of 1.0 possible points.
5. 5.-,# 8>70>@805> nder which circumstance would a nurse not perform a a'inal e6amination on a patient in labor?
An admission to the hospital at the start of labor
When accelerations of the fetal heart rate (FHR) are noted orrect
2n maternal perception of perineal pressure or the ur'e to bear down
When membranes rupture
An accelerated FHR is a positie si'n not re9uirin' a'inal e6amination& ariable decelerations howeer merit a a'inal e6amination. *a'inal e6amination should be performed when the woman is admitted to the hospital or birthin' center at the start of labor. When the woman perceies perineal pressure or the ur'e to bear down is another appropriate time to perform a a'inal e6amination as is after rupture of membranes (R24). he nurse must be aware that there is an increased risk of prolapsed cord immediately after R24. Awarded 0.0 points out of 1.0 possible points. 8. 8.-,# 8>70>@808> When mana'in' the care of a woman in the second sta'e of labor the nurse uses arious measures to enhance the pro'ress of fetal descent. hese measures include#
$ncoura'in' the woman to try arious upri'ht positions includin' s9uattin' and standin'. orrect ellin' the woman to start pushin' as soon as her ceri6 is fully dilated. ontinuin' an epidural anesthetic so that pain is reduced and the woman can rela6. oachin' the woman to use sustained 10: to 1<:second closed:'lottis bearin':down efforts with each contraction.
pri'ht positions and s9uattin' may enhance the pro'ress of fetal descent. 4any factors dictate when a woman will be'in pushin'. omplete cerical dilation is necessary but it is only one factor. -f the fetal head is still in a hi'her pelic station the physician or midwife may allow the woman to Dlabor down (allowin' more time for fetal descent thereby reducin' the amount of pushin' needed) if she is able. An epidural may mask the sensations and muscle control needed for the woman to push effectiely. losed:'lottic breathin' may tri''er the *alsala maneuer which increases intrathoracic and cardioascular pressures reducin' cardiac output and inhibitin' perfusion of the uterus and placenta. -n addition holdin' the breath for lon'er than < to > seconds diminishes the perfusion of o6y'en across the placenta resultin' in fetal hypo6ia. Awarded 0.0 points out of 1.0 possible points. /. /.-,# 8>70>@8058 $idence:based care practices desi'ned to support normal labor and birth recommend which practice durin' the immediate newborn period?
he healthy newborn should be taken to the nursery for a complete assessment. After dryin' the infant should be 'ien to the mother wrapped in a receiin' blanket. !kin:to:skin contact of mother and baby should be encoura'ed. orrect he father or support person should be encoura'ed to hold the infant while awaitin' deliery of the placenta.
he unwrapped infant should be placed on the woman%s bare chest or abdomen then coered with a warm blanket. !kin:to:skin contact keeps the newborn warm preents neonatal infection enhances physiolo'ic adEustment to e6trauterine life and fosters early breastfeedin'. Althou'h complete assessment in the nursery is the practice in many facilities it is neither eidence:based nor supportie of family:centered care. Handin' the mother the blanket:wrapped baby is a common practice and more family friendly than separatin' mother and baby& howeer ideally the baby should be placed on the mother skin to skin. he father or support person is likely also an6ious to hold and admire the newborn. his can happen after the infant has been placed skin to skin with the mother and breastfeedin' h as been initiated. Awarded 0.0 points out of 1.0 possible points.
<. <.-,# 8>70>@8051 Which description of the phases of the second sta'e of labor is accurate?
+atent phase# feels sleepy fetal station is 5M to /M duration is 80 to /< minutes Actie phase# oerwhelmin'ly stron' contractions Fer'uson reflu6 actiated duration is < to 1< minutes ,escent phase# si'nificant increase in contractions Fer'uson reflu6 actiated aera'e duration aries orrect ransitional phase# woman Dlaborin' down fetal station is 0 duration is 1< minutes
he descent phase be'ins with a si'nificant increase in contractions the Fer'uson refle6 is actiated and the duration aries dependin' on a number of factors. he latent phase is the lull or Dlaborin' down period at the be'innin' of the second sta'e. -t lasts 10 to 80 minutes on aera'e. he second sta'e of labor has no actie phase. he transition phase is the final phase in the second sta'e of labor& contractions are stron' and painful. Awarded 0.0 points out of 1.0 possible points. =. =.-,# 8>70>@805< When performin' a'inal e6aminations on a laborin' woman the nurse should be 'uided by what principle?
leanse the ula and perineum before and after the e6amination as needed. orrect Wear a clean 'loe lubricated with tap water to reduce discomfort. 3erform the e6amination eery hour durin' the actie phase of the first sta'e of labor. 3erform an e6amination immediately if actie bleedin' is present.
leansin' will reduce the possibility that secretions and microor'anisms will ascend into the a'ina to the ceri6. 4aternal comfort will also be enhanced.
!terile 'loes and lubricant must be used to preent infection. *a'inal e6aminations should be performed only as indicated to limit maternal discomfort and reduce the risk for transmission of infection especially when rupture of membranes occurs. $6aminations are neer done by the nurse if a'inal bleedin' is present because the bleedin' could be a si'n of placenta preia and a a'inal e6amination could result in further separation of the low:lyin' placenta. Awarded 0.0 points out of 1.0 possible points. >. >.-,# 8>70>@8087 Which test is performed to determine whether membranes are ruptured?
rine analysis
Fern test orrect
+eopold maneuers
AR24
-n many instances a sterile speculum e6amination an d a "itraine (pH) and fern test are performed to confirm that fluid seepa'e is indeed amniotic fluid. A urine analysis should be performed on admission to labor an d deliery to determine the presence or absence of 'lucose and protein. he nurse performs +eopold maneuers to identify fetal lie presentin' part and attitude. AR24 is the procedure of artificially rupturin' membranes usually with a deice known as an amnihook. Awarded 0.0 points out of 1.0 possible points. @. @.-,# 8>70>@808< When assessin' a multiparous woman who has Eust 'ien birth to an @:pound boy the nurse notes that the woman%s fundus is firm and has become 'lobular. A 'ush of dark red blood comes from her a'ina. he nurse concludes that#
he placenta has separated. orrect
A cerical tear occurred durin' the birth.
he woman is be'innin' to hemorrha'e.
lots hae formed in the upper uterine se'ment.
3lacental separation is indicated by a firmly contractin' uterus a chan'e in the uterus from a discoid to a 'lobular ooid shape a sudden 'ush of dark red blood from the introitus an apparent len'thenin' of the umbilical cord and a findin' of a'inal fullness. erical tears that do not e6tend to the a'ina result in minimal blood loss. !i'ns of hemorrha'e are a bo''y uterus bri'ht red a'inal bleedin' alterations in ital si'ns pallor li'htheadedness restlessness decreased urinary output and alteration in the leel of consciousness. -f clots hae formed in the upper uterine se'ment the nurse would e6pect to find the uterus bo''y and displaced to the side. Awarded 0.0 points out of 1.0 possible points. 7. 7.-,# 8>70>@8057 A woman who is 87 weeks pre'nant e6presses fear about h er impendin' labor and how she will mana'e. he nurse%s best response is#
D,on%t worry about it. Gou%ll do fine. D-t%s normal to be an6ious about labor. +et%s discuss what makes you afraid. orrect
D+abor is scary to think about but the actual e6perience isn%t.
DGou may hae an epidural. Gou won%t feel anythin'.
his statement allows the woman to share her con cerns with the nurse and is a therapeutic communication tool. he statement in A ne'ates the woman%s fears and is not therapeutic. he statement in also ne'ates the woman%s fears and offers a false sense of security. he statement in , is not true. A number of criteria must be met for use of an epidural. Furthermore many women still e6perience the feelin' of pressure with an epidural. Awarded 0.0 points out of 1.0 possible points. 10. 10.-,# 8>70>@80/1 Which of the followin' would not be included in a labor nurse%s plan of care for an e6pectant mother?
he onset of pro'ressie re'ular contractions
he bloody or pink show
he spontaneous rupture of membranes
Formulation of the woman%s plan of care for labor orrect
+abor care be'ins when pro'ressie re'ular contractions be'in the blood:tin'ed mucoid a'inal dischar'e appears or fluid is dischar'ed from the a'ina. he woman and the nurse can formulate their plan of care before labor or durin' treatment. Awarded 0.0 points out of 1.0 possible points. 11. 11.-,# 8>70>@8088 -f a woman complains of back labor pain the nurse mi'ht best su''est that she#
+ie on her back for a while with her knees bent.
,o less walkin' around.
ake some deep cleansin' breaths.
+ean oer a birth ball with her knees on the floor. orrect
he hands:and:knees position with or without the aid of a birth ball should help with the back pain. he supine position should be discoura'ed. Walkin' 'enerally is encoura'ed. ,eep cleansin' breaths will assist with any labor pain& howeer it is ery important that this woman%s position is chan'ed so that she is not on her back. Awarded 0.0 points out of 1.0 possible points. 15. 15.-,# 8>70>@8081 -n a ariation of roomin':in called couplet care, the mother and infant share a room and the mother shares the care of the infant with#
he father of the infant.
Her mother (the infant%s 'randmother).
