Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? SATA
--avoid discussing the adoption details until after birth
--encourage the birth mother to hold the newborn
--notify other staff who may interac...
UWorld Maternity Practice Questions &
Answers
Which actions should the labor and delivery nurse perform when caring for a client who
has decided to relinquish her newborn to an adoptive parent? SATA
--avoid discussing the adoption details until after birth
--encourage the birth mother to hold the newborn
--notify other staff who may interact with the client of the adoption plan
--offer the birth mother a chance to say goodbye to the newborn
--use phrases that illustrate adoption as a decision of love, not abandonment - --
encourage the birth mother to hold the newborn
--notify other staff who may interact with the client of the adoption plan
--offer the birth mother a chance to say goodbye to the newborn
--use phrases that illustrate adoption as a decision of love, not abandonment
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm.
Which uterine assessment finding requires an intervention by the nurse?
--contraction duration of 95 seconds
--contraction frequency of every 3 minutes
--contraction intensity of 45 mm Hg
--uterine resting tone of 10 mm Hg - contraction duration of 95 seconds
---normal contraction duration is 45-80 seconds and should not exceed 90 seconds.
Uterine Frequency is 2-5 contractions Q 10 min and should not occur more than every
two minutes.
What is a normal uterine contraction duration during the first stage of labor? - 45-80
seconds not exceeding 90 seconds
What is a normal uterine contraction frequency during the first stage of labor? - 2-5
contractions every 10 minutes, not to occur more frequently than every 2 minutes
What is a normal uterine contraction intensity during the first stage of labor? - 25-50 mm
Hg and should not exceed 80 mm Hg
Define intensity (used to describe labor contractions) - strength of the contraction at its
peak
Define resting tone (used to describe labor contractions) - tension in the uterine muscle
between contractions
Function of the resting tone during labor - allow fetal oxygenation between contractions
,What is a normal resting tone during the first stage of labor? - average is 10 mm Hg and
should not exceed 20 mm Hg
What does a duration of uterine contractions greater than 90 seconds during the first
stage of labor result in? - reduction of blood flow to the placenta due to uterine
hypertonicity
What can occur if uterine contractions occurs less than 2 minutes apart? - fetal distress
due to uteroplacental insufficiency
What is a sign of hypertonicity of the uterus? - an intrauterine pressure more than 80
mm Hg
A client gives birth within an hour of arriving at labor and delivery unit and delivers the
placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline
and boggy. Which action should the nurse take FIRST?
--check for pooled blood under buttocks
--increase IV oxytocin infusion rate
--monitor blood pressure and pulse
--perform firm fundal massage - perform firm fundal massage
What are the clinical features of postpartum uterine atony? - enlarged, soft, boggy,
poorly contracted uterus
What are the risk factors for postpartum uterine atony? - --uterine fatigue from
prolonged, induced, or precipitous labor
--intramniotic infection
--uterine overdistention (multiple gestation, macrosomia, polyhydramnios)
--retained placenta
--grand multiparity (>5 prior deliveries)
What are the interventions for postpartum uterine atony? - --bimanual uterine massage
(INITIAL NURSING ACTION)
--correction of bladder distension
--high-dose oxytocin, misoprostol
--tranexamic acid
--carboprost, methylergonovine (uterotonics)
--intrauterine balloon tamponade
--possible surgical interventions (if unresolved)
What is the function of uterotonics? - stimulate the uterus to contract. Administration is
indicated if the uterus fails to contract despite massage
A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push.
The nurse observed thick, blood-tinged mucus during the vaginal examination. What is
the nurse's BEST action?
,--administer prescribed IV meperidine for pain relief
--encourage client to bear down with spontaneous urges to push
--place client in the lithotomy position in preparation for birth
--provide encouragement and coaching in breathing techniques - provide
encouragement and coaching in breathing techniques
--Meperidine is an opioid occasionally used for analgesia during labor. It should be
avoided within 1-4 hours of birth d/t potential for neonatal respiratory depression. Clients
may feel the urge to push (Ferguson reflex) prior to complete dilation, but pushing
should be delayed until complete dilation is achieved to avoid cervical
swelling/lacerations. The client has not yet reached complete dilation and should be
allowed to move freely, although lithotomy positioning may be more convenient for birth
attendant
Which labor positions encourage fetal rotation and descent, increase client comfort, and
decrease the risk of perineal trauma? - upright or lateral positions
What cm dilation is the period of active labor (AKA transition)? - 8-10 cm
What are the signs of near-complete dilation? - bloody show and urge to push
The precepting nurse is supervising a new obstetric nurse performing a labor admission
assessment on a client with suspected spontaneous rupture of membranes. Which
action by the new nurse would cause the precepting nurse to intervene?
1. Documenting a positive nitrazine test result when the test strip turns blue
2. Donning nonsterile gloves and using soluble gel for vaginal examination
3. Palpating the client's abdomen before applying external fetal monitors
4. Providing the client with a variety of clear liquids to drink - donning nonsterile gloves
and using soluble gel for vaginal examination
--sterile gloves should be utilized during vaginal exam in presence of ruptured
membranes to prevent infection.
Function of nitrazine pH strip test - strip inserted into the vagina to differentiate between
amniotic fluid (alkalitic) and vaginal fluid (acidic)
What color(s) indicate a positive nitrazine pH test strip and probable rupture of
membranes? - blue-green
blue-gray
deep blue
What color(s) indicate a negative nitrazine pH test strip? - yellow
olive-yellow
, olive-green
Function of leopold maneuvers - maneuvers used to assist the nurse in locating the fetal
back for optimal placement of the ultrasound transducer for external fetal heart
monitoring
A nurse is preparing to administer oxytocin to induce labor in a pregnant client in term
gestation. Which of the following nursing actions are appropriate during oxytocin
infusion? SATA
--administer oxytocin through the primary IV line
--assess the uterine contraction pattern
--initiate continuous fetal heart rate monitoring
--place IV oxytocin on an electronic infusion pump
--titrate oxytocin to achieve cervical dilation of 1 cm every 2 hours - --assess the uterine
contraction pattern
--initiate continuous fetal heart rate monitoring
--place IV oxytocin on an electronic infusion pump
---use of electronic infusion pump decreases medication errors, provides accurate
dosing, and prevents maternal hypotension. Oxytocin is administered through a
secondary IV line and is not titrated according to cervical dilation.
How often should the nurse evaluate and document fetal heart rate and uterine
contraction patterns during the first stage of labor?
second stage of labor? - every 15 minutes
every 5 minutes
A primigravid client in early labor is admitted and reports intense back pain with
contractions. The fetal position is determined to be right occiput posterior. Which action
by the nurse would be most helpful for alleviating the client's back pain during early
labor?
--applying counterpressure to the client's sacrum during contractions
--encouraging the client to remain in bed during early labor
--positioning the client on the left side with pillows for support
--requesting that the nurse anesthetist administer epidural anesthesia - applying
counterpressure to the client's sacrum during contractions.
--While left lateral positioning is better for uteroplacental blood flow and fetal
oxygenation than supine positions, it may not alleviate the client's back pain.
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