Exam (elaborations) NURSING 222 MATERNITY INTRAPARTUM NURSING CARE

Exam (elaborations) NURSING 222 MATERNITY INTRAPARTUM NURSING CARE Labor and Delivery Processes, Pain Management, Fetal Assessment During Labor, Nursing Care During Stages of Labor, Therapeutic Procedures to Assist with Labor and Delivery, Complications Related to the Labor Process NURSING 222 MATERNITY INTRAPARTUM NURSING CARE Labor and Delivery Processes PRECEDING LABOR: Backache, Weight loss, Lightening-fetus head drops into pelvis (easier breathing, more pressure on bladder), Braxton Hicks, Increased vaginal discharge or bloody show, energy burst (nesting), and less common GI changes, Cervical ripening, ROM ASSESSMENT OF AMNIOTIC FLUID Clear, watery, pale, straw yellow with no foul odor. 500-1200 mL. Nitrazine paper to determine if amniotic fluid is present. Cervix should dilate 1 –1.5 cm per hour. Every state and phase is shorter if it’s not the first pregnancy. TRUE LABOR—CONTRACTIONS Contractions become regular in frequency. Stronger, last longer, more frequent. Felt in lower back radiating to abdomen. Walking can increase intensity. Continue despite comfort measures TRUE LABOR –CERVIX Progressive change in dilation and effacement. Moves to anterior position. Bloody show. TRUE LABOR-FETUS Presenting part engages in pelvis. FALSE LABOR-CONTRACTIONS Painless, irregular, intermittent. Walking decreases duration and frequency. Felt in lower back or above umbilicus. Often stop with sleep or comfort measures. FALSE LABOR-CERVIX No change in dilation or effacement. Often remains in posterior position. No significant bloody show. FALSE LABOR-FETUS Presenting part is not engaged in pelvis. Labor and Delivery Process Four STAGES First one has 3 PHASES FIRST STAGE LATENT PHASE 0-3 cm Contractions: 5-30 mins, lasting 30-45 seconds FIRST STAGE ACTIVE PHASE 4-7 cm Contractions: 3-5 mins, lasting 40-70 seconds FIRST STAGE TRANSITION 8-10 cm Contractions: 2-3 mins, lasting 45-90 seconds SECOND STAGE 30 min—2 hr Begins at: Full dilation Progresses to intense contractions every 1- 2 min Ends at: Birth THIRD STAGE 5-30 min Begins at: Delivery of the neonate Ends at: Delivery of placenta FOURTH STAGE Begins at: Delivery of placenta Ends at: Maternal stabilization of vital signs We want Cephalic Vertix. LOA (Left, Occipital, Anterior) 5 P’s PASSENGER (fetus and placenta) Presentation: the part of the fetus that is entering the pelvic inlet Lie: Transverse (shoulder at pelvic inlet) or Parallel (with mother’s spine.) Attitude: Chin flexed or extended Stations: -5-0-+5 Fetal position: L or R, Anterior, Posterior, occiput, sacrum, mentum or scapula PASSAGEWAY The birth canal. Includes the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening) POWERS Contractions that cause the cervix to shorten, thin and dilate. Plus the urge to push (FERGUSON REFLEX). POSITION In the U.S. we use lithotomy, but squatting, kneeling, and sitting upright assist w/fetal descent. PHYSIOLOGICAL RESPONSE Maternal stress, tension and anxiety can produce physiological changes that can impair the progress of labor. Pain Management FIRST STAGE Internal visceral pain that can be felt as back and leg pain. Caused by dilation, effacement and stretching of cervix. Contractions. Distention of uterus. CERVIX DILATING AND EFFACING SECOND STAGE Pain that is somatic and occurs with fetal descent and expulsion. Caused by pressure and distention on the vagina and perineum. Lacerations. DELIVERY OF FETUS THIRD STAGE Pain with the expulsion of the placenta is similar to the first stage. Caused by uterine contractions and pressure and pulling of pelvic structures. DELIVERY OF PLACENTA 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. INTERVENTIONS Breathe into paper bag if experiencing hyperventilation (caused by low levels of PCO3 from blowing off too much CO2). Effleurage: light, gentle, circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions. ANALGESIA –SEDATIVES secobarbital penobarbital and phenobarbital Not used often. Sedative can relieve anxiety and induce sleep. Not administered if birth is imminent in 12-24 hrs. Can cause respiratory depression in the fetus. ANALGESIA-OPIODS Butorphanol and nalbuphine, IM or IV Do not cause significant respiratory distress in fetus. Can decrease FHR variability. Side effects include emesis, hypotension, tachycardia, lack of bladder/bowel function Cannot be given close to deliveryrespiratory distress. ANTI-NAUSEA AND ANXIETY Onadansetron and metoclopramide Used with opioids, together help reduce pain. EPIDURAL AND SPINAL REGIONAL ANALGESIA Pain meds w/o anesthesia Fentanyl and sufentanil Rapid pain relief, client can still feel contractions and bear down. Elevates temp. Brady/tachycardia. Hypotension. Respiratory depression. Emesis. PUDENAL BLOCK Administered transvaginally into the space in front of the pudenal nerve. Local anesthesia for the perineum, vulva and rectal areas for episiotomy or episotomy repairs. Late 2nd stage of labor to 20 min before delivery. Effects maternal bearing down reflex. May cause hematoma. EPIDURAL BLOCK Local anesthesia (bupivacaine), fentanyl or morphine injected into the epidural space at the 4th or 5th vertebrae. Eliminates all sensation from the umbilicus to the thighs. Active labor, dilated at least 4cm. Fetal bradycardia, maternal hypotension. Can’t feel urge to void or the bear down reflex. Catheterize if necessary. SPINAL ANESTHESIA All sensations from nipples to feet. Used for C/S. A low spinal block can be used for vaginal birth, but not for labor. Late second stage or before C/S. Fetal bradycardia, maternal hypotension. Headache from CSF leakage. GENERAL ANESTHESIA-rarely used Fetal Assessment During Labor V Variable Decelerations Absent or undetectable variability (nonreassuring). Minimal variability (less than 5/min). Moderate (6 to 25/min). Marked (greater than 25/min). Episodic is not associated with contractions. Periodic occurs w/contractions. E Early decelerations Slowing of FHR with start of contraction with return to baseline at end of contraction. No intervention required. A Accelerations Healthy fetal exchange. Reassuring. No intervention required. L Late Decelerations Slowing of FHR after contraction has started with return well after contraction has ended. C Cord compression. Short cord. Prolapsed cord. Nuchal cord. Knee to chest or side to side position. Discontinue oxytocin. Administer O2. Perform vaginal examination to see cord. Assist with amnioinfusion if prescribed. H Head compression O Oxygenation P Placental insufficiency Maternal hypotension, placenta previa, abruptio placentaa, uterine hyperstimulation w/oxytocin, preeclampsia, late or post-term pregnancy, diabetes Place client in side lying positon, increase rate of IV fluids, discontinue oxytocin, administer O2, elevate legs, notify HCP LEOPOLD MANEUVERS External palpations to determine number of fetuses, presenting part, fetal lie, fetal attitude, degree of descent of presenting part, location of the fetus’s back to assess for heart tones. Vertex: fetal heart tones should be assessed below the umbilicus, R or L lower quad of abdomen Breech: above umbilicus, R or L upper quad of abdomen CONSIDERATIONS Empty bladder Supine position Place a small, rolled towel under the client’s L or R hip to displace the uterus off major blood vessels to prevent hypotension. ONGOING CARE At the fundus, the head should feel round, firm and move freely. If breech, it should feel irregular and soft FHR monitoring Latent phase: every 30-60 min Active phase: every 15-30 min Second stage: every 5-15 min Continuous internal fetal monitoring— determines intensity of contractions. Accurately assesses FHR variability. Not effected by obesity or position changes. Can only be done if membranes have ruptured, cervix is at least 2-3cm dilated, risk of infection. Need special training to perform procedure. Fetal Assessment During Labor FETAL BRADYCARDIA Less than 110/ min for 10 min or more CAUSES/COMPLICATIONS: Placental insufficiency. Cord prolapse. Hypotension. Prolonged cord compression. Fetal congenital heart block. Anesthetics. Viral infection. Hypoglycemia. Fetal heart failure. Maternal hypothermia. NURSING INTERVENTIONS: Discontinue oxytocin. Assist to side lying. Administer oxygen. Administer a tocolytic. FETAL TACHYCARDIA More than 160/ min for 10 min or more CAUSES/COMPLICATIONS Maternal infection. Chorioamnionitis. Fetal anemia. Fetal cardiac dysrhythmias. Maternal use of cocaine or amphetamines. Maternal dehydration. Maternal or fetal infection. Maternal hyperthyroidism. NURSING INTERVENTIONS: Administer antipyretics if fever is present. Administer oxygen. Administer IV fluid bolus. Therapeutic Procedures to Assist with Labor and Delivery EXTERNAL CEPHALIC VERSION Used for a malpositioned fetus in breech or transverse position after 36 weeks. High risk of placental abruption, umbilical cord compression and emergency C/S. Need to test for Rh antibodies and give immunoglobulin. Fetal bradycardia and variable decelerations. Maternal hypotension. BISHOP SCORE Used to determine readiness for labor. Cervical dilation, effacement, consistencyfirm, medium, soft, Cervical positionposterior, mid, anterior, station of presenting part Each factor assigned a value from 0-3 +8 multiparous, +10 nulliparous CERVICAL RIPENING Low-dose infusion of oxytocin. Balloon catheter. Membrane stripping and amniotomy. Hygroscopic dilators (seaweed or mag sulfate) Oral or suppository prostaglandin E: misoprostol, dinoprostone COMPLICATIONS: Hyperstimulation. Administer subcut injection of terbutaline. Fetal distress: Administer O2. Position client on left side. Increase rate of IV fluid. Notify HCP. INDUCTION OF LABOR Greater than 39 weeks, Bishop score Postterm pregnancy, dystocia, prolonged ROM, Maternal medical complications like hypertension/diabetes, fetal demise, chorioamnioitis. Cervical ripening-amniotomy-oxytocin infusion. DESIRED CONTRACTION PATTERN: Frequency of 2-3 min Duration of 60-90 seconds Intensity of 40-90 mm Hg Resting tone of 10-15 mm Hg Dilation of 1 cm/hr Reassuring FHR of 110-160/min Discontinue oxytocin if outside those parameters. AUGMENTATION OF LABOR The stimulation of hypotonic contractions once labor has spontaneously begun, but progress is inadequate. AMNIOTOMY Artificial ROM by using an Amnihook or other sharp instrument. Increased risk of cord prolapse or infection. FHR, FHR, FHR. Monitor maternal temp. AMNIOINFUSION NS or LR instilled into the amniotic cavity via catheter to supplement amniotic fluid. INDICATIONS: Uteroplacental insufficiency, premature ROM, Postmaturity of fetus. Fetal cord compression from macrosomic fetus. Warm fluid first. FHR. Monitor for fluid distention. FORCEPS ASSISTED BIRTH Spoon like blades. Complications: Cervical, vaginal and perineal lacerations. Injury to the bladder. Facial nerve palsy and bruising of the neonate. VACUUM ASSISTED DELIVERY Used for: vertex presentation, absence of cephalopelvic disproportion, ruptured membranes. Maternal exhaustion, fetal distress during 2nd stage. Risks: lacerations, hematoma/ cephalohematoma Generally not used before 34 weeks. EPISIOTOMY Shortens the 2nd stage of labor. Prevents cerebral hemorrhage in a fragile preterm fetus. Facilitates birth of macrosomic infant. Median - toward recturm. Mediolateral-to left or right midline. Cesarean birth and Vaginal birth after cesarean (VBAC) CESAREAN BIRTH Transabdominal incision delivery to preserve health of client and fetus when there is evidence of complications. Incisions made horizontally. INDICATIONS: Malpresentation (breech), cephalopelvic disproportion, nonreassuring fetal heart tone, placenta previa, abruptio placentae, high-risk pregnancies (HIV, pre/ eclampsia, diabetes, herpes lesions), previous C/S, dystocia, multiple gestations, umbilical cord prolapse NURSING ACTIONS: Position in supine position with a wedge under one hip. NPO. Rh factor test. POSTPROCEDURE: A tender uterus and foul-smelling lochia can indicate endometritis. COMPLICATIONS: Aspiration, amniotic fluid pulmonary embolism, wound infection, wound dehiscence, severe abdominal pain, thrombophlebitis, hemorrhage, UTI, injuries to bladder or bowel, anesthesia complications VBAC No other uterine scars or history of previous rupture. Clinically adequate pelvis. No current contraindications-LGA, malpresentation, cephalopelvic disproportion Complications Related to the Labor Process PROLAPSED UMBILICAL CORD Cord is displaced, preceding the presenting part, or protruding from the cervix resulting in cord compression and compromised fetal circulation. RISK FACTORS: ROM, abnormal presentation (other than vertex-occiput), transverse lie, SGA, unusually long umbilical cord, multifetal pregnancy, unengaged presenting part, hydramnios or polyhydramnios. EXPECTED FINDINGS: Visually see cord. Client can feel it coming through vagina. FHR has variable or prolonged decelerations. Excessive fetal activity followed by cessation of activity due to severe fetal hypoxia. NURSING CARE Knee chest or Trendelenburg. Sterile glove to lift presenting part off ord. Apply warm, sterile, saline soaked towel to cord to prevent drying and maintain blood flow. Oxygen. IV fluid bolus. FHR and notify HCP. MECONIUM STAINED AMNIOTIC FLUID Prior to start of labor-unfavorable outcome. Increased risk after 38 wks. Cord compression leading to hypoxia causes release of meconium. EXPECTED FINDINGS: Black, greenish, yellow or brown amniotic fluid. (Often green). Can be thin or thick. Often present in breech. Stained fluid accompanied by variable or late decelerations is an ominous sign. NURSING CARE Notify neonatal resuscitation team. Suction mouth and nose if respiratory efforts are strong. Suction via endotracheal tube if respirations are depressed and HR 100/min. FETAL DISTRESS FHR below 100 or above 160/min Decreased or no variability. Fetal hyperactivity or no fetal activity. RISK FACTORS: Fetal anomalies. Uterine anomalies. Complications of labor and birth. NURSING CARE: Position client in left side lying reclining position w/legs elevated. Administer oxygen. Discontinue oxytocin. Increase IV fluid if hypotension present. Prep for C/S. Complications Related to the Labor Process DYSTOCIA (DYSFUNCTIONAL LABOR) Difficult or abnormal labor related to the five P’s. Aypical uterine contractions can be hypotonic or hypertonic. RISK FACTORS: Short stature, overweight, age 40 yrs., uterine abnormalities, pelvic soft tissue obstructions or contracture, cephalopelvic disproportion, congenital anomalies, macrosomia, malpresentation, multifetal pregnancy, maternal fatigue/fear/dehydration, inappropriate timing of anesthesia or analgesics. EXPECTED FINDINGS: Hypotonic-weak, inefficient or completely absent contractions. Hypertonic-excessively frequent, uncoordinated, strong intensity and inadequate contractions. Occiput posterior presentation prolongs labor and pain. NURSING CARE: Fetal scalp electrode or intrauterine pressure catheter. Amniotomy. Encourage regular voiding, ambulation and position changes. Apply sacral counterpressure. Maintain hydration. Oxytocin for hypotonic only. PRECIPITOUS LABOR Labor that lasts 3hrs or less from onset of contractions to time of delivery. Hypertonic uterine dysfunctioncontractions are too long and frequent, but not causing progression. Can be caused by oxytocin administration. Multiparous clients more likely to move through stages of labor more quickly. EXPECTED FINDINGS: Low backache. Abdominal pressure and cramping. Increased bloody discharge. Palpable uterine contractions. Diarrhea. Membranes can be intact or ruptured. Trauma or lacerations in perineal area. Neonate may be hypoxic. Trauma to presenting part of neonate. NURSING CARE: Do not leave client unattended. Encourage panting between contractions to control urge to push. Side-lying position. Apply light pressure to perineal area and fetal head pressing upward to vagina to ease rapid expulsion of fetus and prevent cerebral damage to newborn and lacerations. Deliver fetus BETWEEN contractions to assure no nuchal cord. COMPLICATIONS: Cervical, vaginal, perineal lacerations. Tissue trauma. Uterine rupture. Amniotic fluid embolism. Postpartum hemorrhage. Fetal hypoxia due to hypertonic contractions or nuchal cord. Fetal intracranial hemorrhage due to head trauma. UTERINE RUPTURE Complete or incomplete rupture of uterus. Rare, but life-threatening. RISK FACTORS: Congenital uterine abnormality. Uterine trauma due to accident/surgery. Overdistention of uterus from LGA, multifetal or polyhydramnios. Hyperstimulation of uterus. External or internal fetal version done. Forceps-assisted birth. Multigravida clients. EXPECTED FINDINGS: Client reports sharp, ripping/tearing pain. Nonreassuring FHR w/variable and late decelerations, absent or minimal variability. Fetal parts are palpable w/change in uterine shape. Cessation of contractions. Hypovolemic shock-tachypnea, hypotension, pallor, cool/clammy skin. NURSING CARE: Administer IV fluids. Administer oxygen. Administer blood transfusions if prescribed. Prep for immediate C/S plus hysterectomy. Complications Related to the Labor Process ANAPHYLCATOID SYNDROME OF PREGNANCY (AMNIOTIC FLUID EMBOLISM) Rupture in amniotic sac or maternal uterine veins accompanied by high uterine pressure that cause infiltration of amniotic fluid into maternal circulation. Travels to and obstructs respiratory vessels. Can occur anytime during labor up to 30 min after birth. Meconium-stained amniotic fluid can cause devastating maternal damage because it clogs pulmonary veins completely. DIC can occur. RISK FACTORS: Multiparity or advanced maternal age. Placenta previa or abruption. Pre/ Eclampsia. Oxytocin. Diabetes. C/S. Forceps assisted birth. Uterine rupture. Cervical laceration. Meconium-stained amniotic fluid. EXPECTED FINDINGS: Sudden chest pain and/or shortness of breath. Restlessness, cyanosis, dyspnea, pulmonary edema, respiratory arrest. Bleeding from incisions and venipuncture sites. Petechiae and ecchymosis. Uterine atony. Signs of DIC. Tachycardia, hypotension, shock, cardiac arrest. NURSING CARE: Administer O2. Assist with intubation and mechanical ventilation. Perform CPR. Administer IV fluids. Positon client on side with pelvis at 30 degree angle to displace the uterus. Administer blood products for DIC. Insert an indwelling urinary catheter. Prep for emergency C/S if applicable. The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The spontaneous urge to push is initiated from perineal pressure. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 mm3 (12.0 × 109 /L) A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a –2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Late decelerations 1 Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment. 3, 5 The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1. 3, 5 In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage. 4 Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction. 3, 5 Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part. 2 A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11–13 g/dL (110–130 mmol/L) ) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 x 10 9 /L), up to 18,000 mm3 (18 x 109 /L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 x 109 /L) because of increased leukocytosis that occurs during delivery. A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi Fowler's position with a pillow under the knees The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity." Which assessment following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure 4 Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary. 1 A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention. 1 Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi Fowler's position is not practical for this type of abdominal surgery. 3 Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy. 4 True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor. 2 Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin. 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L (3.6 mmol/L) The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal