Family Exam 3

Term
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A nurse is caring for a client at 40 weeks of gestation who is experiencing contractions every e to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take at this time? (select all that apply)

A. Encourage the use of patterned breathing techniques.
B. Insert an indwelling urinary catheter.
C. Administer opioid analgesic medication as prescribed.
D. Suggest application of cold.
E. Provide ice chips.
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Terms in this set (30)
A nurse is caring for a client at 40 weeks of gestation who is experiencing contractions every e to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take at this time? (select all that apply)

A. Encourage the use of patterned breathing techniques.
B. Insert an indwelling urinary catheter.
C. Administer opioid analgesic medication as prescribed.
D. Suggest application of cold.
E. Provide ice chips.
A. Encourage the use of patterned breathing techniques.

C. Administer opioid analgesic medication as prescribed.

D. Suggest application of cold.


Encouraging the use of patterned breathing techniques can assist with pain management at this time. An opioid analgesic can be safely administered at this time. The use of a nonpharmacological approach, such as the application of cold, is an appropriate intervention at this time.
A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions is appropriate?

A. Abdominal effleurage
B. Sacral counterpressure
C. Showering if not contraindicated
D. Back rub and massage
B. Sacral counterpressure

Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus.
A nurse is caring for a client following the administration of an epidural block and is preparing to administer a prescribed IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following is an appropriate response by the nurse?

A. "It is need to promote increased urine output."
B. "It is needed to counteract respiratory depression."
C. "It is needed to counteract hypotension."
D. "It is needed to prevent oligohydramnios."
C. "It is needed to counteract hypotension."

Maternal hypotension can occur following an epidural block and can be offset by administering a fluid bolus.
A nurse in the labor and delivery unit is caring for a client who is in the second stage of labor. The client's labor has been progressing, and she is expected to deliver vaginally in 20 min. The provider is preparing to administer lidocaine (Xylocaine) for pain relief and perform an episiotomy. The nurse should know that the type of regional anesthetic block that is to be administered is to which of the following?

A. Pudendal block
B. Epidural block
C. Spinal block
D. Paracervical block
A. Pudendal block

A pundendal block is a transvaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy and repair, and the expulsion of the fetus.
Describe the underlying principle for the use of sensory stimulation and cutaneous strategies
Underlying Principle
Gate control theory of pain is based on the concept that the sensory nerve pathways that pain sensations use to travel to the brain will allow only a limited number of sensations to travel at any given time. By sending alternate signals through these pathways, the pain signals can be blocked from ascending the neurological pathway and inhibit the brain's perception and sensation of pain.
Sensory Stimulation Strategies
• Aromatherapy
• Imagery
• Use of focal points
• Breathing techniques
• Music
Cutaneous Strategies
• Back rubs and massage
• Sacral counterpressure
• Hydrotherapy
• Effleurage (Light, gentle circular stroking of the client's abdomen with the fingertips in rhythm with breathing during contraction
• Heat or cold therapy
• Acupressure
Other tidbits from ATI Chapter 12 (pages 132-141)
Naloxone (Narcan), an opioid antagonist, should be readily available for reversal of opioid-induced respiratory depression.

Ondansetron (Zofran) and metoclopramide (Reglan) can control nausea and anxiety. They do not relieve pain and are used as an adjunct with opioids.
Sources of pain during the stages of labor
First stage- internal visceral pain that may be felt as back and leg pain, which is caused by dilation, effacement, stretching of the uterus, distention of the lower segment of the uterus, and contractions of the uterus with resultant uterine ischemia.

Second stage- pain that is somatic and occurs with fetal descent and expulsion. Pain is caused by pressure and distention of the vagina and perineum, describe by the client as "burning, splitting, and tearing"; pressure and pulling on the pelvic structures (ligaments, fallopian tubes, ovaries, bladder, and peritoneum); lacerations of soft tissues (cervix, vagina, and perineum)

Third stage- pain with the expulsion of the placenta is similar to the pain experienced during first stage. Pain is caused by uterine contractions, pressure and pulling of pelvic structures

Fourth stage- pain is caused by distention and stretching of the vagina and perineum incurred during the second stage with a splitting, burning, and tearing sensation.

*SAFETY for the mother and fetus must be the first consideration of the nurse when planning pain management measures.
A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increase beat-to-beat variability of 20/min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (select all that apply)

A. Moderate variability
B. FHR accelerations
C. FHR decelerations
D. Normal baseline FHR
E. Fetal tachycardia
A. Moderate variability.
There is a moderate variability of 20 beats/min (6 to 25/min is expected)

B. FHR accelerations
FHR accelerations are present with increases up to 150 to 155/min lasting for 25 seconds

D. Normal baseline FHR
There is a normal baseline of FHR of 115 to 125/min (110 to 160/min is expected.
A nurse is caring for a client who is having an induction of labor. Based on the use of external electronic fetal monitoring, the nurse notes that the FHR variability is decreased and resembles a straight line. The client has not received any pain medication. Which of the following should occur first before the nurse can apply an internal scalp electrode? A. Dilation B. Rupture of the membranes C. Effacement D. EngagementB. Rupture of the membranes The membranes must be ruptured prior to the insertion of an internal electrode or intrauterine pressure catheter.A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse knows that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractionsD. Relaxation between uterine contractions A fetus is most oxygenated during the relaxation period between contractions. During contractions, the arteries to the uteroplacental intervillous spaces are compressed, resulting in a decrease in fetal circulation and oxygen.A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal examA. Assist the client into the left-lateral position The greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The initial nursing action should be to place the client into the left-lateral position to increase uteroplacental perfusion.A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply both hands to the sides of the uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.B. Palpate the fundus of the uterus Palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse)A nurse in labor and delivery is reviewing intermittent fetal auscultation and uterine contraction palpation with a recently hired nurse. What should be included in the review? A. Indications: Describe 4 situations when this procedure should be performed. B. Interpretation of Findings: Describe normal expected FHR findings. C. Nursing Actions: Preprocedure: Describe the three types of devices that are used to auscultate the FHR. Intraprocedure: Identify the time frame for counting FHR to determine the baseline rate and when auscultation should take place.A. Indications • Rupture of membranes, spontaneously or artificial • Preceding and subsequent to ambulation • Prior to and following administration of or a change in medication analgesia • At the peak action of anesthesia • Following vaginal examination • Following expulsion of an enema • After urinary catheterization • In the event of abnormal or excessive uterine contractions B. Interpretation of Findings A normal, reassuring FHR is 110 to 160/min with increases and decreases from baseline C. Nursing Actions Preprocedure • Hand-held Doppler ultrasound • Ultrasound stethoscope • Fetoscope Intraprocedure • Count FHR for 30 to 60 seconds to determine the baseline rate • Auscultate during and for 30 seconds following the contractionA nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following is an appropriate response by the nurse? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."C. "The vaginal area will bulge as the baby's head appears." Crowning is bulging of the perineum and the appearance of the fetal head.A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation has occurred? (Select all that apply) A. Lengthening of the umbilical cord. B. Swift gush of clear amniotic fluid. C. Softening of the lower uterine segment. D. Appearance of dark blood from the vagina. E. Fundus is firm upon palpation.A. Lengthening of the umbilical cord. The umbilical cord lengthens as the placenta is being expulsed. D. Appearance of dark blood from the vagina. A gush of dark blood from the introitus is an indication of placental separation. E. Fundus is firm upon palpation. The uterus contracts firmly with placental separation.A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following is an appropriating nursing intervention? A. Assist the client to the bathroom B. Prepare for an impending delivery C. Prepare to remove a fecal impaction D. Encourage the client to take deep, cleansing breaths.B. Prepare for an impending delivery The urge to have a bowel movement indicates fetal descent and complete dilation. Preparing for an imminent delivery is appropriate.A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.D. Defer vaginal examinations. Vaginal examinations should not be performed until placenta previa or placenta abruptio has been ruled out as the cause of vaginal bleeding.A nurse is caring for a client who is in the first stage of labor and encourages the client to void every 2 hr. The nurse explains that a A. full bladder increases the risk for fetal trauma. B. full bladder increases the risk for bladder infections. C. distended bladder will be traumatized by frequent pelvic exams. D. distended bladder reduces pelvic space needed for birth.D. distended bladder reduces pelvic space needed for birth. A distended bladder reduces pelvic space, impedes fetal descent, and places the bladder at risk for trauma during the labor process.A nurse is caring for a client in the fourth stage of labor. What actions should the nurse take? A. Underlying Principles: Describe B. Nursing Interventions: Describe fourA. Underlying Principles • The focus of care in the fourth stage is to maintain uterine tone and to prevent hemorrhage B. Nursing Interventions • Assess vital signs, fundus, and lochia every 15 min for the first hour, then according to facility protocol • Massage the uterus • Encourage voiding to prevent bladder distention • Promote parental-newborn bondingA nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. The nurse should know that an amnioinfusion is indicated for which of the following reasons? (Select all that apply) A. Oligohydramnios B. Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturityA. Oligohydramnios Oligohydramnios is an indication for an amnioinfusion because inadequate amniotic fluid can contribute to intrauterine growth restriction of the fetus, restrict fetal movement, and cause fetal distress during labor. C. Fetal cord compression Olgiohydramnios results in fetal cord compression, which decreases fetal oxygenation. Amnioinfusion prevents cord compression.A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? A. Fetal engagement B. Fetal lie C. Fetal attitude D. Fetal positionA. Fetal engagement Prior to the performance of an amniotomy, the amniotic membranes shoudl have ruptured. It is also imperative that the fetus is engaged at 0 station and at the level of the maternal ischial spines to prevent prolapse of the umbilical cord.A nurse is caring for client who had no prenatal care, is Rh-negative and will undergo an external version at 37 weeks of gestation. The nurse anticipates a prescription for which of the following medications to be administered prior to the version? A. Prostaglandin gel (Cervidel) B. Magnesium sulfate C. Rho (D) immune globulin (RhoGAM) D. Oxytocin (Pitocin)C. Rho (D) immune globulin (RhoGAM) Rho(D) immune globulin (RhoGAM) is adminstered to an Rh-negative client at 28 weeks of gestation. Because this client had no prenatal care, it should be given prior to the version to prevent isoimmunization.A nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A. Frequency of every 2 min B. Duration of 90 to 120 seconds C. Intensity of 60 to 90 mm Hg D. Resting tone of 15 mm HgB. Duration of 90 to 120 seconds Oxytocin is discontinued if uterine hyperstimulation occurs with contraction duration longer than 90 seconds.A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "They are administered in an oral form." B. "They act by absorbing fluid from tissues." C. "They promote dilation of the os." D. "They include an amniotomy."A. "They are administered in an oral form." Chemical agents that promote cervical ripening include medications administered in oral form.A nurse is planning care for a client who experienced a cesarean birth. What should be included in the plan of care? A. Procedure: Describe. B. Indications: Describe at least 4 C. Nursing Actions: Describe 4 that are preprocedure D. Complications: Describe two that are maternal and two that are fetalA. Procedure • Delivery of the fetus through a transabdominal incision of the uterus to preserve the life or health of the client and fetus when there is evidence of complications; incisions are made horizontally into the lower uterine segment. B. Indications • Malpresentation, breech • Multiple gestations • Cephalopelvic disproportion • Fetal distress • Placental previa • Abruptio placenta • HIV-positive status • Dystocia • Umbilical cord prolapse • Eclampsia • Preeclampsia • Active herpes lesions • Previous cesarean birth C. Nursing Actions • Assess and record FHR, vital signs • Assist with ultrasound • Position client in a supine position with a wedge under one hip • Insert an indwelling urinary catheter • Administer preoperative medications as prescribed • Prepare the surgical site • Insert an IV catheter, and administer IV fluids as prescribed • Obtain signed informed consent form • Determine client's NPO status • Verify preoperative testing results • Provide emotional support D. Complications • Maternal o Aspiration o Amniotic fluid pulmonary embolism o Wound infection o Wound dehiscence o Severe abdominal pain o Thrombophlebitis o Hemorrhage o Urinary tract infection o Injury to bladder or bowel o Anesthesia-associated complications • Fetal o Premature birth o Fetal injury during surgeryA nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse recognizes the adverse effect of this contraction patter is A. prolonged labor B. reduced fetal oxygen supply C. delayed cervical dilation D. increased maternal stress.B. reduced fetal oxygen supply Inadequate uterine relaxation results in reduced oxygen supply to the fetus.A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. Lithotomy C. Trendelenburg D. Supine with a rolled towel under one hipA. Hands and knees Having the client assume a position on her hands and knees may help the fetus rotate from a posterior to an anterior position.A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C. Postmaturity syndrome D. Prolapsed umbilical cordD. Prolapsed umbilical cord A prolapsed umbilical cord is a potential complication for a fetus in a breech presentation.