A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse? Show
Prepare for birth, reposition the patient, and begin pushing. 4 Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.
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Get faster at matching terms Terms in this set (61)During a counseling discussion of nutrition, a nurse explains to a pregnant client that she will need additional calcium during pregnancy and that the best source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." What is the nurse's best reply? "Your practitioner can prescribe calcium supplements." The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test? Instruct her to void immediately before the test During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. What should the nurse advise the client about her position when she sleeps? "Turn from side to side." A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by: Compression by the enlarging uterus A client in her 37th week of gestation calls a nurse in the prenatal clinic and reports, "My ankles are swollen." What should the nurse recommend? Elevating her legs more frequently during the day A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor? Take a walk around the unit with her A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain? By acting on opioid receptors to reduce pain A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say? Telling the mother, "I'm sorry, but I need to ask you to stay in the waiting area." A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond During the eighth week of the pregnancy A client is scheduled for amniocentesis. What should the nurse do before the procedure? Remind the client to empty her bladder A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What should the nurse do first? Inspect her perineal area A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement "Nurse at least every 3 hours for at least 10 minutes on each breast." While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information? G5 T1 P1 A2 L2 A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder? High level of chorionic gonadotropin A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.9 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? "Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet." What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? Assist the client's coach in helping her with the use of breathing techniques A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. Which nursing action is best delegated to a licensed practical nurse/licensed vocational nurse (LPN/LVN) who also works on the unit? Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10
A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2013. Using Naegele's Rule, what date in June 2014 is the client's estimated date of birth (EDB)? Record your answer as a whole number. ________ 21 At 9 pm visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention? Encouraging the sister to participate in care as much as the client wishes Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward: Helping the client maintain control A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution? The amount of lochia rubra is moderate When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured? Test the leaking fluid with nitrazine paper A client is admitted in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify? First A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with: Doppler ultrasound at 10 to 12 weeks What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? Moderate serosa A vaginal examination reveals that a client in labor is dilated 7 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering? Transition During labor the nurse encourages the client to void periodically. The nurse knows that an over distended urinary bladder during labor can: Predispose the client to uterine hemorrhage after birth
A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client? Water intoxication A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect. (Select all that apply.) Amenorrhea What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor? Uterine tetany A laboring client has asked the nurse help her to use a nonpharmacological strategy for pain management. Name the sensory simulation strategy Selecting a focal point and beginning breathing techniques A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? Greenish-tinged amniotic fluid What findings occur with supine hypotensive syndrome? (Select all that apply.) Feeling of
faintness A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? (Select all that apply.) "My ears are ringing." A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing action? Placing the report in the client's record because this is an expected postpartum finding What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? (Select all that apply.) Pain management with oral analgesics A client at 35 weeks' gestation is experiencing contractions. Her cervix is dilated 2 cm. The nurse teaches the client that sexual activity, particularly intercourse, should be: Avoided to limit the onset of labor What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen? Intrusion on movement A client in active labor is admitted to the birthing room. A vaginal examination reveals that the cervix is dilated 6 to 7 cm. In light of this finding, the nurse expects that the: Client's contractions will become longer and more frequent A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she is leaking breast milk. The best response is to tell her that: This can be a normal occurrence during pregnancy After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. The nurse notes that the fetus' head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder? Gently guiding the head downward A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment? Empty her bladder The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter? "I'm not exactly sure how an epidural works." After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? Below the umbilicus on the right side What is the best nursing intervention to minimize perineal edema after an episiotomy? Applying ice packs A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? Encourage the family to bring in special foods preferred in their culture While waiting for his 39-year-old wife to change clothes after an amniocentesis, the husband says to the nurse, "I sure hope that they don't find anything wrong because of my wife's age. I don't know how we'd deal with a child with Down syndrome. We already have two small children at home." What is the nurse's best response? "It must be difficult, worrying about whether your baby will be disabled." A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time? Neural tube defect A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history? G5 T2 P1 A1 L4 After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time? Massaging the client's fundus One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? Continue periodic evaluations and record the findings The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum? Enlarging area of caput with each contraction A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation? There will be weekly retesting because, at this time, the fetus has oxygen reserves. What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? (Select all that apply.) Smoker A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn? "The cardiac sphincter relaxes and allows acid to be regurgitated." During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain: "The heart rate is usually rapid, and this one is in the expected range." A 24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include? 340 more calories during the second trimester A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take? Discontinuing the test because the pattern is reassuring How should a nurse direct care for a client in the transition phase of the first stage of labor? Helping the client maintain control A pregnant woman at 6 week's gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? (Select all that apply.) Stop taking the supplement immediately. Discuss the use of the supplement with the practitioner Discuss the use of any over-the-counter products with the practitioner. \In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action? 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A client in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The client may hyperventilate, resulting in nausea and vomiting.
What is the nurse's priority assessment for a client in the fourth stage of labor?What is the nurse's priority assessment for a client in the fourth stage of labor? A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric.
Which nursing instruction would ensure fetal safety during the second stage of labor?Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet.
Which instruction does the nurse give to a client who arrives in the birthing room with the fetal head crowning quizlet?A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse instruct the client to do? Use the pant-breathing pattern.
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How should a nurse direct care for a client in the transition phase of the first stage of labor quizlet?
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