Maternity
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal
examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced
and that the presenting part is at 0 station. What is the location of the presenting part?
At the level of the ischial spines - ANS-The ischial spines are used as landmarks in relation
to the fetus's head, because they reflect the progression of labor; 0 station indicates that the
presenting part is at the ischial spines. When the head enters the vagina it is below the
ischial spines and its position is designated with positive numbers (+1 to +4). When the
presenting part is floating, the fetus is at -5 station. A position above the ischial spines is
designated by a minus number (-1 to -4)
\A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an
alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds
that this test can reveal what?
Neural tube defects - ANS-The alpha-fetoprotein test can detect not only neural tube
defects, but also Down syndrome and other congenital anomalies. It is a screening test that
affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the
kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
\A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult.
How should the nurse respond?
"Your diaphragm has been displaced upward." - ANS-The pressure of the enlarging fetus
causes upward displacement of the diaphragm, which results in thoracic breathing; this limits
the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become
restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage
enlarges; it does not rise.
\A client in active labor has requested epidural anesthesia for pain management . The
anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid
bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, & the large amount of IV fluid reduces this risk. - ANS-Once
an epidural is initiated there is a risk of hypotension (low blood pressure), which may result
in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural
medication is administered through a catheter placed by the anesthetist. Quoting institutional
policy does not provide the explanation for administering the solution. Providing 500 mL of
fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of
determining that the line is patent before the administration of medication.
\A client in active labor starts screaming, "The baby is coming! Do something!" What is the
nurse's primary action?
Checking the perineal area for the presenting part - ANS-The primary action by the nurse
should be to confirm whether birth is imminent by checking the perineal area to determine
whether the presenting part is emerging. Confirming the client's sensation is the priority; the
, nurse should remain with the client and ask a colleague to call the practitioner if birth is
imminent. Stating that birth is not imminent demeans the client, and she may be correct.
Holding the knees together is contraindicated. If birth is imminent, this could cause injury to
the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
\A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45
seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min
on the internal fetal monitor. What is the priority nursing action?
Notifying the healthcare provider - ANS-Bradycardia (baseline FHR slower than 110
beats/min) indicates that the fetus may be compromised, requiring medical intervention.
Resuming continuous fetal heart monitoring may be dangerous. The fetus may be
compromised, and time should not be spent on monitoring. Continuing to monitor the
maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min
between contractions.
\A client is admitted to the birthing unit in active labor. Which physiologic changes should the
nurse anticipate after an amniotomy is performed?
Progressive dilation & effacement - ANS-Artificial rupture of the membranes (amniotomy)
allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation
and effacement. Vaginal bleeding may increase because of the progression of labor.
Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater
because contractions usually increase in intensity and frequency after the membranes are
artificially ruptured.
\A client is bleeding excessively after the birth of her newborn. The healthcare provider
prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100
mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood
pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the
right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?
Checking for a distended bladder. - ANS-A displaced and boggy uterus is usually the result
of a full bladder; if the bladder is distended, the nurse should have the client void and then
reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin
infusion may need to be increased if voiding and fundal massage are ineffective; however,
the healthcare provider must be notified to change the order. Continuing to perform fundal
massage is necessary if the fundus remains boggy after the client has voided. Continuing to
assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the
priority.
\A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What
should the nurse do first?
Inspect her perineal area - ANS-Inspection of the perineum is performed to determine
whether rupture of the membranes has occurred and whether the umbilical cord has
prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the
priority, although it is done eventually if the membranes have ruptured. An oral temperature
should be taken after it has been established that the membranes have ruptured.
\A pregnant client asks the clinic nurse how smoking will affect her baby. What information
about cigarette smoking will influence the nurse's response?
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal
examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced
and that the presenting part is at 0 station. What is the location of the presenting part?
At the level of the ischial spines - ANS-The ischial spines are used as landmarks in relation
to the fetus's head, because they reflect the progression of labor; 0 station indicates that the
presenting part is at the ischial spines. When the head enters the vagina it is below the
ischial spines and its position is designated with positive numbers (+1 to +4). When the
presenting part is floating, the fetus is at -5 station. A position above the ischial spines is
designated by a minus number (-1 to -4)
\A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an
alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds
that this test can reveal what?
Neural tube defects - ANS-The alpha-fetoprotein test can detect not only neural tube
defects, but also Down syndrome and other congenital anomalies. It is a screening test that
affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the
kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
\A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult.
How should the nurse respond?
"Your diaphragm has been displaced upward." - ANS-The pressure of the enlarging fetus
causes upward displacement of the diaphragm, which results in thoracic breathing; this limits
the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become
restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage
enlarges; it does not rise.
\A client in active labor has requested epidural anesthesia for pain management . The
anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid
bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, & the large amount of IV fluid reduces this risk. - ANS-Once
an epidural is initiated there is a risk of hypotension (low blood pressure), which may result
in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural
medication is administered through a catheter placed by the anesthetist. Quoting institutional
policy does not provide the explanation for administering the solution. Providing 500 mL of
fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of
determining that the line is patent before the administration of medication.
\A client in active labor starts screaming, "The baby is coming! Do something!" What is the
nurse's primary action?
Checking the perineal area for the presenting part - ANS-The primary action by the nurse
should be to confirm whether birth is imminent by checking the perineal area to determine
whether the presenting part is emerging. Confirming the client's sensation is the priority; the
, nurse should remain with the client and ask a colleague to call the practitioner if birth is
imminent. Stating that birth is not imminent demeans the client, and she may be correct.
Holding the knees together is contraindicated. If birth is imminent, this could cause injury to
the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
\A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45
seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min
on the internal fetal monitor. What is the priority nursing action?
Notifying the healthcare provider - ANS-Bradycardia (baseline FHR slower than 110
beats/min) indicates that the fetus may be compromised, requiring medical intervention.
Resuming continuous fetal heart monitoring may be dangerous. The fetus may be
compromised, and time should not be spent on monitoring. Continuing to monitor the
maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min
between contractions.
\A client is admitted to the birthing unit in active labor. Which physiologic changes should the
nurse anticipate after an amniotomy is performed?
Progressive dilation & effacement - ANS-Artificial rupture of the membranes (amniotomy)
allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation
and effacement. Vaginal bleeding may increase because of the progression of labor.
Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater
because contractions usually increase in intensity and frequency after the membranes are
artificially ruptured.
\A client is bleeding excessively after the birth of her newborn. The healthcare provider
prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100
mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood
pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the
right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?
Checking for a distended bladder. - ANS-A displaced and boggy uterus is usually the result
of a full bladder; if the bladder is distended, the nurse should have the client void and then
reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin
infusion may need to be increased if voiding and fundal massage are ineffective; however,
the healthcare provider must be notified to change the order. Continuing to perform fundal
massage is necessary if the fundus remains boggy after the client has voided. Continuing to
assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the
priority.
\A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What
should the nurse do first?
Inspect her perineal area - ANS-Inspection of the perineum is performed to determine
whether rupture of the membranes has occurred and whether the umbilical cord has
prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the
priority, although it is done eventually if the membranes have ruptured. An oral temperature
should be taken after it has been established that the membranes have ruptured.
\A pregnant client asks the clinic nurse how smoking will affect her baby. What information
about cigarette smoking will influence the nurse's response?
