Nursing Care During Labor and Birth, Exams of Nursing

Download Nursing Care During Labor and Birth and more Exams Nursing in PDF only on Docsity! CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING, 7TH EDITION 1. The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position ANS: C Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A pH test or fern test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 2. Which comfort measure should the nurse utilize in order to enable a laboring woman to relax? a. Recommend frequent position changes. b. Palpate her filling bladder every 15 minutes. c. Offer warm wet cloths to use on the patient’s face and neck. d. Keep the room can see everything. ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief. Soft indirect lighting is more soothing than irritating bright lights. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 3. Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING, 7TH EDITION DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 4. Which intervention is an essential part of nursing care for a laboring patient? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety ANS: A Helping a patient manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important; however, managing pain is a top priority. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 5. A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences a. increased fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus. ANS: C assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 6. Which patient at term should proceed to the hospital or birth center the immediately after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours. ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A zero station indicates engagement. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 13. During labor a vaginal examination should be performed only when necessary because of the risk of a. infection. b. fetal injury. c. discomfort. d. perineal trauma. ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 14. A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and contraction. Suddenly, the patient pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely a. a sign of abnormal labor progress. b. an indication that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor. ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Psychosocial Integrity 15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s trunk is pink and the hands and feet are blue. The Apgar score for this infant is a. 7. b. 8. c. 9. d. 10. ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant’s blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant’s hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant’s hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity 16. If a woman’s fundus is soft 30 minutes after birth, the nurse’s first action should be to a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position. ANS: A The nurse’s first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 17. The nurse thoroughly dries the infant immediately after birth primarily to a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface. ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 18. The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant. Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Psychosocial Integrity 19. Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours. a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety due to fear of the unknown. It would be important to recognize this because the patient is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor patients includes the use of parenteral fluid therapy; the patient should be monitored for FVD and, if symptoms warrant, receive intervention. Because the patient has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara patient. Although the patient may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. The patient is entering the second stage of labor; therefore she will be allowed to push with contractions. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Nursing Diagnosis MSC: Patient Needs: Psychosocial Integrity 20. Which of the following behaviors would be applicable to a nursing diagnosis of “risk for injury” in a patient who is in labor? a. Length of second-stage labor is 2 hours. b. Patient has received an epidural for pain control during the labor process. c. Patient is using breathing techniques during contractions to maximize pain relief. d. Patient is receiving parenteral fluids during the course of labor to maintain hydration. ANS: B A patient who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Diagnosis MSC: Patient Needs: Safe and Effective Care Environment/Management of Care b. c. The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is performed by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the inlet determines whether the head is flexed (vertex) or extended (face). DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 27. After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma? a. Lack of an episiotomy b. Mild, intermittent perineal pain c. Lack of pain in the perineal area d. Edema and discoloration of the labia and perineum ANS: D The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 28. Which patient presentation is an acceptable indication for serial oxytocin induction of labor? a. Multiple fetuses b. Polyhydramnios c. History of long labors d. Past 42 weeks of gestation ANS: D Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus, making induction of labor high risk. Polyhydramnios also overdistends the uterus, creating a high risk for induction. A history of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 29. The nurse is explaining the technique of internal version to a nursing orientee. Which statement best describes the technique of internal version? a. Manipulation of the fetus from a breech to a cephalic presentation before labor begins b. Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth c. Manipulation of the second twin from an oblique lie to a transverse lie before labor begins d. Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth ANS: D Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal version is done to turn the second twin after the first twin is born. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 30. A maternal indication for the use of vacuum extraction is a. a wide pelvic outlet. b. maternal exhaustion. c. a history of rapid deliveries. d. failure to progress past 0 station. ANS: B The patient who is exhausted will be unable to assist with the expulsion of the fetus. With a wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum extraction would not be necessary. A station of 0 is too high for a vacuum extraction. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 31. For which patient should the oxytocin (Pitocin) infusion be discontinued immediately? a. A patient in transition with contractions every 2 minutes lasting 90 seconds each b. A patient in early labor with contractions every 5 minutes lasting 40 seconds each c. A patient in active labor with contractions every 3 minutes lasting 60 seconds each d. A patient in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each ANS: A This patient’s contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this patient’s contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this patient’s contractions. There is an appropriate resting period between this patient’s contractions for her stage of labor. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity 32. Immediately following the forceps-assisted birth of an infant, which action should the nurse implement? a. Assess the infant for signs of trauma. b. Apply a cold pack to the infant’s scalp. Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infant’s face. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance 39. Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth? a. Anterior fontanel b. Coronal suture lines c. Posterior fontanel d. Biparietal diameter ANS: C The vacuum extractor is applied on the occipital bone and may create scalp edema at the application site. The posterior fontanel connects the occipital bone to the parietal bones. The anterior fontanel, coronal suture lines, and parietal bones are not part of the application area for a vacuum extractor. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance 40. Which breech presentation should the nurse recognize as being favorable for an external cephalic version? a. 36-week gestation with low-lying placenta b. 38-week gestation with c. 37-week gestation with fetal weight of 7 lb d. 40-week gestation with several uterine fibroids ANS: C An external cephalic version (changing the fetal presentation from breech to cephalic) is more successful when the pregnancy is at least 37 weeks and there is still adequate room and fluid to manipulate the fetus but prior to term or onset of labor. A low-lying placenta, previous cesarean birth, and uterine fibroids are contraindications for version. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation 41. Following an external cephalic version, which assessment finding indicates a complication? a. Onset of irregular contractions b. Maternal blood pressure of 110/70 mm Hg c. Deceleration of FHR to 88 bpm d. Maternal pulse rate of 100 bpm ANS: C A serious risk of external cephalic version is that the fetus may become entangled in the umbilical cord, compressing its vessels and resulting in hypoxia. The onset of irregular contractions, maternal blood pressure of 110/70 mm Hg, and maternal pulse rate of 100 bpm are normal findings. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation 42. The pregnant patient expresses a desire to schedule birth during the baby’s father’s furlough from military service. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding? a. Dilated cervix b. Fetal lung maturity c. Rupture of membranes d. Uterine hypertonia ANS: B Reassurance of fetal lung maturity is essential before elective procedures such as induction or cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction. Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor associated with induction of labor. DIF: Cognitive Level: Knowledge OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 43. The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2 C (99 F). What is the priority nursing action for this patient? a. Fetal acoustic stimulation b. Assess temperature every 2 hours c. Change absorption pads d. Review white blood cell count (WBC) drawn at admission ANS: B The woman’s temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38C (100.4F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time d. Faster descent of the fetus e. An increase in frequency of contractions ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body’s signals. A brief slowing of contractions often occurs at the beginning of the second stage. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity 2. Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant’s head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed. ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant’s. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 3. When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor. ANS: B, C, D