1
Q
According to the source material, who are the three clients an intrapartum nurse should care for during labor and delivery?
A
The fetus, the mother, and the family unit.
2
Q
What is the term for the physiologic changes preceding labor?
A
Premonitory signs.
3
Q
What premonitory sign of labor is described as the fetal head descending into the true pelvis, making breathing easier but increasing urinary frequency?
A
Lightening.
4
Q
What is the risk associated with a prolonged rupture of membranes greater than 24 hours before birth?
A
Infection.
5
Q
What is the first action a nurse should take immediately following the rupture of membranes?
A
Assess the Fetal Heart Rate (FHR) for abrupt decelerations to rule out umbilical cord prolapse.
6
Q
A client at 39 weeks of gestation reports fluid leaking from her vagina for 2 days. For which condition is this client at risk?
A
Infection.
7
Q
What are the five factors that affect and define the labor and birth process, known as the ‘Five P’s’?
A
Passenger (fetus and placenta), passageway (birth canal), powers (contractions), position (of the client), and psychological response.
8
Q
In the context of the ‘Five P’s’ of labor, what does ‘Passenger’ refer to?
A
The fetus and the placenta.
9
Q
What is the term for the part of the fetus that enters the pelvic inlet first?
A
Presentation.
10
Q
A fetal lie where the fetal long axis is horizontal to the maternal axis is known as _____.
A
Transverse.
11
Q
In fetal positioning, what does the first letter (R or L) in the three-letter abbreviation reference?
A
The side of the maternal pelvis.
12
Q
In fetal positioning, what does the second letter (O, S, M, Sc) in the three-letter abbreviation reference?
A
The presenting part of the fetus (Occiput, Sacrum, Mentum, Scapula).
13
Q
What is the term for the measurement of fetal descent in centimeters relative to the ischial spines?
A
Station.
14
Q
A fetal station of 0 indicates that the presenting part is at the level of the _____.
A
Ischial spines.
15
Q
What do the ‘Powers’ of labor refer to?
A
Uterine contractions and the involuntary urge to push.
16
Q
How do frequent position changes during labor benefit the client?
A
They increase comfort, relieve fatigue, and promote circulation.
17
Q
In true labor, contractions become more regular and walking can _____ their intensity.
A
Increase.
18
Q
What is the key difference in the cervix between true labor and false labor?
A
In true labor, there is a progressive change in dilation and effacement; in false labor, there is no significant change.
19
Q
During a vaginal examination, what three assessment findings can be determined?
A
Cervical dilation/effacement/position, fetal presenting part/position/station, and status of membranes.
20
Q
In the first stage of labor, what is the cause of internal visceral pain?
A
Dilation, effacement, and stretching of the cervix.
21
Q
In the second stage of labor, what type of pain occurs with fetal descent and expulsion?
A
Somatic pain described as burning, splitting, and tearing.
22
Q
What is the underlying principle of the gate-control theory of pain?
A
Sensory nerve pathways allow only a limited number of sensations to travel at once, so alternate signals can block pain signals.
23
Q
If a laboring client using patterned breathing reports lightheadedness and tingling fingers, what is the likely cause?
A
Hyperventilation (blowing off too much CO2).
24
Q
What is the appropriate nursing intervention for a client hyperventilating during labor?
A
Have the client breathe into a paper bag or their cupped hands.
25
What is effleurage?
Light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions.
26
For a client with lower-back pain from a persistent occiput posterior fetal position, what nonpharmacological intervention is recommended?
Sacral counterpressure.
27
When should opioid analgesics like meperidine or fentanyl be administered during labor to avoid slowing its progress?
During the early part of active labor, after verifying that labor is well established.
28
What is a major adverse effect of administering opioid analgesics to a mother too close to the time of delivery?
Respiratory depression in the neonate.
29
What opioid antagonist should be readily available for reversal of opioid-induced respiratory depression?
Naloxone.
30
What type of regional anesthetic block is administered transvaginally into the space in front of the pudendal nerve for perineal anesthesia?
Pudendal block.
31
When is a pudendal block typically administered?
During the late second stage of labor, 10 to 20 minutes before birth.
32
An epidural block consists of a local anesthetic and an analgesic injected into the epidural space at the level of the _____ or _____ vertebrae.
Fourth or fifth.
33
What is the primary nursing action to help offset maternal hypotension before an epidural block is administered?
Administer a bolus of IV fluids.
34
What is a common maternal adverse effect of an epidural or spinal block?
Maternal hypotension.
35
After an epidural catheter is inserted, why should the client be encouraged to remain in a side-lying position?
To avoid supine hypotension syndrome from compression of the vena cava.
36
A spinal anesthesia (block) involves injecting a local anesthetic into which space?
The subarachnoid space.
37
What is a potential adverse effect of a spinal block related to leakage of cerebrospinal fluid?
A potential headache.
38
What are interventions for a postpartum headache resulting from a cerebrospinal fluid leak after a spinal block?
Placing the client supine, promoting bed rest in a dark room, administering analgesics, caffeine, fluids, and an autologous blood patch.
39
When is general anesthesia typically used for childbirth?
Only in the event of a delivery complication or emergency when there is a contraindication to nerve block anesthesia.
40
What is the purpose of Leopold maneuvers?
To determine the presenting part, fetal lie, attitude, degree of descent, and location of the fetus's back for FHR assessment.
41
For a fetus in a vertex presentation, where should fetal heart tones be assessed?
Below the client's umbilicus in either the right or left lower quadrant of the abdomen.
42
For a fetus in a breech presentation, where should fetal heart tones be assessed?
Above the client's umbilicus in either the right or left upper quadrant of the abdomen.
43
How does uterine relaxation between contractions benefit the fetus?
It allows maternal blood flow to resume into the uterus and placenta, restoring fetal circulation and oxygenation.
44
What is the normal baseline fetal heart rate (FHR) range at term?
110 to 160/min.
45
FHR tachycardia is defined as a FHR greater than _____/min for 10 minutes or longer.
160
46
FHR bradycardia is defined as a FHR less than _____/min for 10 minutes or longer.
110
47
Term: Fetal heart rate baseline variability
Definition: Fluctuations in the FHR baseline that are irregular in frequency and amplitude.
48
What is considered the expected or normal type of FHR variability?
Moderate variability (6 to 25/min).
49
What is the classification for FHR variability that is detectable but equal to or less than 5/min?
Minimal variability.
50
A Category I fetal heart rate tracing includes a baseline FHR of 110-160/min, moderate variability, and the absence of _____ or _____ decelerations.
Variable or late.
51
Category III fetal heart rate tracings are considered abnormal and include either a sinusoidal pattern or absent baseline FHR variability with what other findings?
Recurrent variable decelerations, recurrent late decelerations, or bradycardia.
52
What are transitory, abrupt increases in the FHR above baseline called, which indicate a healthy fetal/placental exchange?
Accelerations.
53
What is the cause of early decelerations of the FHR?
Compression of the fetal head.
54
What is the required nursing intervention for early decelerations?
No intervention is required as it is a benign finding.
55
What is the appearance of a late deceleration on a fetal monitor tracing?
Slowing of FHR after the contraction has started, with a return to baseline well after the contraction has ended.
56
What is the primary cause of late decelerations of the FHR?
Uteroplacental insufficiency causing inadequate fetal oxygenation.
57
What is the first action a nurse should take when observing late decelerations on the electronic fetal monitor?
Assist the client into a side-lying position.
58
List three nursing interventions for a client experiencing late decelerations.
Place client in side-lying position, increase IV fluids, and discontinue oxytocin if infusing.
59
What is the appearance of a variable deceleration on a fetal monitor tracing?
Transitory, abrupt slowing of FHR that is variable in duration, intensity, and timing in relation to uterine contractions.
60
What is the primary cause of variable decelerations of the FHR?
Umbilical cord compression.
61
What is a priority nursing intervention for variable decelerations?
Reposition the client from side to side or into a knee-chest position.
62
What are two advantages of continuous internal fetal monitoring compared to external monitoring?
Accurate assessment of FHR variability and accurate measurement of uterine contraction intensity.
63
What are two requirements for the use of continuous internal fetal monitoring?
Membranes must have ruptured and the cervix must be adequately dilated (minimum 2-3 cm).
64
What is the term for the shortening and thinning of the cervix during the first stage of labor?
Effacement.
65
What is the term for the enlargement or widening of the cervical opening that occurs once labor has begun?
Dilation.
66
In the first stage of labor, the _____ phase is from 0-5 cm dilation, and the _____ phase is from 6-10 cm dilation.
latent/early; active
67
During which phase of the first stage of labor are contractions more regular, moderate to strong, with a frequency of 1.5 to 5 minutes?
Active phase.
68
During which phase of the first stage of labor is the mother often talkative or calm and able to walk through most contractions?
Latent/Early phase.
69
What term describes the relationship of the fetal longitudinal axis (spine) to the maternal longitudinal axis (spine)?
Lie.
70
What term describes the relationship of fetal body parts to one another?
Attitude.
71
The ideal fetal attitude is _____, where the chin is flexed to the chest and extremities are flexed into the torso.
fetal flexion
72
How often should maternal temperature be checked if the membranes are ruptured?
Every 2 hours.
73
A prolonged contraction duration (greater than 90 seconds) or too frequent contractions can reduce blood flow to the placenta, resulting in what fetal condition?
Fetal hypoxia.
74
In the mechanism of labor, what is the term for when the presenting part passes the pelvic inlet at the level of the ischial spines (station 0)?
Engagement.
75
After the birth of the head, it rotates back to the position it occupied as it entered the pelvic inlet. This is known as _____.
External rotation (restitution).
76
During the fourth stage of labor, how often should the fundus and lochia be assessed for the first hour?
Every 15 minutes.
77
An intrapartum nurse should care for which three distinct clients during labor and delivery?
The fetus, the mother, and the family unit.
78
What physiologic change preceding labor is characterized by the fetal head descending into the true pelvis, making breathing easier but increasing urinary frequency?
Lightening.
79
The expulsion of the cervical mucus plug, which can be brownish or blood-tinged, is known as what premonitory sign of labor?
Increased vaginal discharge or bloody show.
80
What is the first action a nurse should take immediately following the rupture of membranes?
Assess the Fetal Heart Rate (FHR) for abrupt decelerations to rule out umbilical cord prolapse.
81
A prolonged rupture of membranes greater than how many hours before birth can lead to an infection?
24 hours.
82
Amniotic fluid is alkaline, causing nitrazine paper to turn what color, indicating a pH of 6.5 to 7.5?
Deep blue.
83
What are the 'Five P's' that affect and define the labor and birth process?
Passenger (fetus and placenta), passageway (birth canal), powers (contractions), position (of the client), and psychological response.
84
In the context of the 'Five P's', what does 'Passenger' refer to?
The fetus and the placenta.
85
What term describes the part of the fetus that enters the pelvic inlet first?
Presentation.
86
A _____ fetal lie occurs when the fetal long axis is horizontal, forming a right angle to the maternal axis, and will not accommodate a vaginal birth.
transverse
87
What is the ideal fetal attitude for navigating the birth canal?
Fetal flexion, where the chin is flexed to the chest and extremities are flexed into the torso.
88
In the three-letter abbreviation for fetopelvic position (e.g., ROA), what does the first letter (R or L) signify?
It references the right or left side of the maternal pelvis.
89
In the three-letter abbreviation for fetopelvic position, what does the second letter (O, S, M, Sc) reference?
The presenting part of the fetus (Occiput, Sacrum, Mentum, or Scapula).
90
What does 'station' measure in labor?
The measurement of fetal descent in centimeters relative to the ischial spines.
91
A fetal station of 0 indicates that the presenting part is at what level?
The level of the maternal ischial spines.
92
In the 'Five P's', what does 'Powers' refer to?
Uterine contractions that cause effacement and dilation, and the involuntary urge to push.
93
What is the term for the shortening and thinning of the cervix during the first stage of labor?
Effacement.
94
What is the term for the enlargement or widening of the cervical opening and canal during labor?
Dilation.
95
During the first stage of labor, the latent/early phase is characterized by cervical dilation from _____ cm to _____ cm.
0 to 5
96
During the first stage of labor, the active phase is characterized by cervical dilation from _____ cm to _____ cm.
6 to 10
97
What are the maternal characteristics typically observed during the latent/early phase of labor?
The mother is talkative or calm, with thoughts focused on labor, self, and baby.
98
How are true labor contractions distinguished from false labor contractions in terms of activity?
True labor contractions can increase in intensity with walking, while false labor contractions often stop with sleep or comfort measures.
99
What cervical changes are characteristic of true labor?
Progressive change in dilation and effacement, and movement to an anterior position.
100
If a pregnant client who is Group B streptococcus positive does not have results from screening available, what is the prescribed nursing action?
An intravenous prophylactic antibiotic is prescribed.
101
If membranes are ruptured, how often should the nurse check the maternal temperature?
Every 2 hours.
102
A prolonged contraction duration greater than _____ seconds can reduce blood flow to the placenta.
90
103
More than _____ contractions in a 10-minute period without sufficient time for uterine relaxation can result in fetal hypoxia.
five
104
In the mechanism of labor, _____ occurs when the largest diameter of the fetal head passes the pelvic inlet at station 0.
engagement
105
During which mechanism of labor does the fetal head bring the chin close to the chest to present a smaller diameter?
Flexion.
106
During the fourth stage of labor, how often should the fundus and lochia be assessed for the first hour?
Every 15 minutes.
107
What is a primary nursing action to maintain uterine tone and prevent hemorrhage in the fourth stage of labor?
Massage the uterine fundus and/or administer oxytocics as prescribed.
108
What causes the internal visceral pain felt as back and leg pain during the first stage of labor?
Dilation, effacement, and stretching of the cervix and distention of the lower uterus.
109
Pain in the second stage of labor is described as somatic and is caused by what?
Pressure and distention of the vagina and perineum, and pressure on pelvic structures.
110
What is the underlying principle of the gate-control theory of pain?
Sensory nerve pathways allow only a limited number of sensations to travel at a time, so alternate signals can block pain signals.
111
If a client using patterned breathing exercises experiences lightheadedness and tingling of the fingers, what is the likely cause and nursing intervention?
Hyperventilation; have the client breathe into a paper bag or their cupped hands.
112
Term: Effleurage
Definition: Light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions.
113
Term: Sacral counterpressure
Definition: Consistent pressure applied to the client's sacral area to counteract pain in the lower back, often associated with a posterior fetal position.
114
Why should sedatives like secobarbital not be administered if birth is anticipated within 12 to 24 hours?
They can cause neonate respiratory depression because the medication crosses the placenta.
115
What opioid antagonist should be readily available for reversal of opioid-induced respiratory depression in the mother or neonate?
Naloxone.
116
Epidural and spinal regional analgesia use short-acting opioids like fentanyl to provide rapid pain relief while allowing the client to still sense _____.
contractions
117
A _____ block is a local anesthetic administered transvaginally to provide anesthesia to the perineum, vulva, and rectal areas during delivery and repair.
pudendal
118
What is a primary nursing action to help offset maternal hypotension before an epidural block is administered?
Administer a bolus of IV fluids.
119
After an epidural catheter is inserted, the client should be encouraged to remain in what position to avoid supine hypotension syndrome?
Side-lying position.
120
A spinal anesthesia (block) eliminates all sensations from the level of the _____ to the feet.
nipples
121
What is a potential adverse effect of spinal anesthesia caused by leakage of cerebrospinal fluid at the puncture site?
A potential headache.
122
What is the most beneficial and reliable relief measure for a headache caused by a cerebrospinal fluid leak after spinal anesthesia?
An autologous blood patch.
123
Before administering general anesthesia, what medication may be given to neutralize acidic stomach contents?
An oral antacid.
124
General anesthesia can cause decreased uterine tone postpartum, which can lead to what complication?
Hemorrhage.
125
What is the purpose of performing Leopold maneuvers?
To determine the presenting part, fetal lie, attitude, degree of descent, and location of the fetus's back for FHR assessment.
126
If a fetus is in a vertex presentation, where should the nurse assess for fetal heart tones?
Below the client's umbilicus in either the right or left lower quadrant of the abdomen.
127
If a fetus is in a breech presentation, where should the nurse assess for fetal heart tones?
Above the client's umbilicus in either the right or left upper quadrant of the abdomen.
128
To prevent supine hypotensive syndrome during Leopold maneuvers, a rolled towel should be placed under the client's _____.
right or left hip
129
A fetus receives more oxygen during which part of the uterine contraction cycle shown on a tracing?
Relaxation between uterine contractions.
130
What is the normal range for a fetal heart rate baseline at term?
110 to 160 beats per minute.
131
What is fetal heart rate tachycardia?
A FHR greater than 160/min for 10 minutes or longer.
132
What is fetal heart rate bradycardia?
A FHR less than 110/min for 10 minutes or longer.
133
FHR baseline variability is described as fluctuations in the FHR baseline. What is considered expected or moderate variability?
6 to 25 beats per minute.
134
An absent or undetectable FHR variability is considered a _____ finding.
nonreassuring
135
What is the primary disadvantage of using an external tocotransducer for monitoring uterine contractions?
Contraction intensity is not measurable.
136
A Category I fetal heart rate tracing requires a baseline rate of 110-160/min, moderate variability, and the absence of which two types of decelerations?
Variable or late decelerations.
137
A sinusoidal FHR pattern is classified as which category in the three-tier system?
Category III.
138
What do FHR accelerations indicate?
A healthy fetal/placental exchange and a reactive nonstress test.
139
What is a potential cause of fetal bradycardia?
Uteroplacental insufficiency, umbilical cord prolapse, or maternal hypotension.
140
What is a common cause of fetal tachycardia?
Maternal infection or fever.
141
A decrease or loss of FHR variability can be caused by medications that depress the CNS or by _____.
fetal hypoxemia and metabolic acidemia
142
What causes early decelerations of the FHR?
Compression of the fetal head.
143
Are nursing interventions required for early decelerations?
No, they are considered a benign finding.
144
What is the cause of late decelerations of the FHR?
Uteroplacental insufficiency causing inadequate fetal oxygenation.
145
What is the first nursing action for a client experiencing late decelerations on the electronic fetal monitor?
Place the client in a side-lying position.
146
What is the primary cause of variable decelerations of the FHR?
Umbilical cord compression.
147
What nursing interventions are appropriate for variable decelerations?
Reposition the client from side to side or into a knee-chest position and discontinue oxytocin if infusing.
148
What is a primary advantage of continuous internal fetal monitoring with a scalp electrode?
It allows for an accurate assessment of FHR variability.
149
What are two requirements for the use of continuous internal fetal monitoring?
Membranes must have ruptured, and the cervix must be adequately dilated (minimum of 2 to 3 cm).
150
An intrauterine pressure catheter (IUPC) is used to accurately measure the _____ of contractions.
intensity
151
A client is at risk for developing an infection if fluid has been leaking from her vagina for two days. What condition is this associated with?
Prolonged rupture of membranes.
152
A client reports contractions that increased with activity and did not decrease with rest, along with bloody show. These are manifestations of what?
True contractions.
153
A client in active labor with a persistent occiput posterior fetal position reports lower-back pain. What nonpharmacological intervention is most effective?
Sacral counterpressure.
154
A provider is preparing to perform an episiotomy on a client in the late second stage of labor. Which type of regional anesthetic block is most likely to be administered?
Pudendal block.
155
A client experiences numbness and tingling of the fingers while using patterned breathing. What is the appropriate nursing action?
Place an oxygen mask over the client's nose and mouth to help them rebreathe CO2.
156
FHR tracing shows a baseline of 120/min, moderate variability, and occasional increases to 150/min for 25 seconds. What does this indicate?
Moderate variability, FHR accelerations, and a normal baseline FHR.
157
What technique should a nurse use to identify the fetal lie during Leopold maneuvers?
Palpate the fundus of the uterus to identify the fetal part occupying it.
158
According to intrapartum nursing care principles, who are the three clients that should be cared for during each labor and delivery?
The fetus, the mother, and the family unit.
159
What are the cervical dilation parameters for the latent/early phase of the first stage of labor?
0 cm to 5 cm.
160
What are the cervical dilation parameters for the active phase of the first stage of labor?
6 cm to 10 cm.
161
Describe the contraction frequency and duration during the latent/early phase of the first stage of labor.
Frequency is 2 to 30 minutes, and duration is 30 to 40 seconds.
162
Describe the contraction frequency and duration during the active phase of the first stage of labor.
Frequency is 1.5 to 5 minutes, and duration is 40 to 90 seconds.
163
What is a common maternal characteristic regarding discharge during the latent/early phase of labor?
A scant amount of brownish discharge, pale pink mucus, or expulsion of the mucus plug.
164
During which phase of labor does the client become more serious, with feelings of helplessness and an inward focus?
The active phase of the first stage of labor.
165
The premonitory sign of labor characterized by the fetal head descending into the true pelvis is known as _____.
Lightening.
166
What is the typical weight loss a client might experience as a premonitory sign of labor?
0.5 to 1.5 kg (1 to 3.5 lb).
167
What is the term for the premonitory sign of labor involving a sudden burst of energy?
Nesting response.
168
A prolonged rupture of membranes greater than _____ before birth can lead to an infection.
24 hours.
169
What is the first nursing action immediately following a rupture of membranes?
Assess the Fetal Heart Rate (FHR) for abrupt decelerations to rule out umbilical cord prolapse.
170
What color will nitrazine paper turn if amniotic fluid is present, and what does this indicate about the fluid's pH?
The paper will turn deep blue, indicating an alkaline pH of 6.5 to 7.5.
171
List the five factors that affect and define the labor and birth process, known as the 'Five P's'.
Passenger (fetus and placenta), passageway (birth canal), powers (contractions), position (of the client), and psychological response.
172
In the context of the 'Five P's', what does 'passenger' refer to?
The fetus and the placenta.
173
Fetal _____: The relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine).
lie
174
What is a transverse lie, and can it accommodate a vaginal birth?
The fetal long axis is horizontal to the maternal axis; it will not accommodate a vaginal birth.
175
Define fetal attitude.
The relationship of fetal body parts to one another.
176
What is the optimal fetal attitude for birth?
Fetal flexion, with the chin flexed to the chest and extremities flexed into the torso.
177
In the three-letter abbreviation for fetal position (e.g., ROA), what does the first letter (R or L) signify?
The side of the maternal pelvis the presenting part is on (Right or Left).
178
In the three-letter abbreviation for fetal position, what does the second letter (O, S, M, Sc) reference?
The presenting part of the fetus (Occiput, Sacrum, Mentum, or Scapula).
179
What is station 0 in fetal descent?
Station 0 is when the presenting part is at the level of the maternal ischial spines.
180
What do 'powers' in the 'Five P's' refer to?
Uterine contractions, which cause effacement and dilation, and the involuntary urge to push.
181
Why should a laboring client engage in frequent position changes?
To increase comfort, relieve fatigue, and promote circulation.
182
What are Leopold maneuvers used to determine?
The fetal presenting part, lie, attitude, descent, and the location for auscultating fetal heart tones.
183
If a Group B streptococcus (GBS) culture is positive, what intervention is prescribed?
An intravenous prophylactic antibiotic.
184
If a client's membranes are ruptured, how often should the maternal temperature be checked?
Every 2 hours.
185
Uterine contraction _____: The strength of the contraction at its peak, described as mild, moderate, or strong.
intensity
186
What potential fetal complication can result from contractions lasting longer than 90 seconds or occurring more than five times in 10 minutes?
Fetal hypoxia and a decreased FHR due to reduced blood flow to the placenta.
187
What is the purpose of an intrauterine pressure catheter (IUPC)?
To be inserted inside the uterus to measure and display uterine contraction patterns, including intensity.
188
The first cardinal movement of labor, when the presenting part passes the pelvic inlet at station 0, is called _____.
engagement
189
The cardinal movement where the fetal head flexes, bringing the chin to the chest to present a smaller diameter, is called _____.
flexion
190
During the cardinal movement of _____, the fetal head passes under the symphysis pubis and is born.
extension
191
How often should a nurse assess the fundus and lochia during the first hour of the fourth stage of labor?
Every 15 minutes.
192
What is the primary difference between true labor and false labor contractions?
True labor contractions become regular in frequency, stronger, and longer, while false labor contractions are irregular and often stop with comfort measures.
193
What cervical change is characteristic of true labor?
Progressive change in dilation and effacement, with the cervix moving to an anterior position.
194
What is the primary cause of internal visceral pain during the first stage of labor?
Dilation, effacement, and stretching of the cervix.
195
The pain in the second stage of labor is described as somatic and is caused by what?
Pressure and distention of the vagina and perineum, and pressure on pelvic structures.
196
What is the Gate-Control Theory of Pain?
The concept that sensory nerve pathways allow only a limited number of sensations to travel at a time, so alternate signals can block pain signals.
197
What is a potential side effect of patterned breathing, and what is the nursing intervention?
Hyperventilation (lightheadedness, tingling fingers); have the client breathe into a paper bag or cupped hands.
198
What is effleurage?
Light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions.
199
For a client with lower-back pain from a persistent occiput posterior position, what nonpharmacological intervention is recommended?
Sacral counterpressure.
200
Why should sedatives (barbiturates) not be administered if birth is anticipated within 12 to 24 hours?
They can cause neonate respiratory depression because the medication crosses the placenta.
201
What opioid antagonist should be readily available for reversal of opioid-induced respiratory depression?
Naloxone.
202
What is a pudendal block used for?
It provides local anesthesia to the perineum, vulva, and rectal areas during delivery, episiotomy, and repair.
203
When is a pudendal block typically administered?
During the late second stage of labor, 10 to 20 minutes before birth.
204
What is a major adverse effect of an epidural block, and what is the prophylactic nursing action?
Maternal hypotension; the nursing action is to administer a bolus of IV fluids beforehand.
205
How should a client be positioned after an epidural catheter is inserted?
In a side-lying position to avoid supine hypotension syndrome.
206
A spinal anesthesia (block) eliminates all sensation from the level of the _____ to the feet.
nipples
207
What is a potential adverse effect of spinal anesthesia related to cerebrospinal fluid leakage?
A potential headache.
208
What is the most beneficial relief measure for a post-dural puncture headache (from a spinal block)?
An autologous blood patch.
209
General anesthesia increases the postpartum risk for _____, due to decreased uterine tone.
hemorrhage
210
To prevent supine hypotensive syndrome during Leopold maneuvers, what should the nurse do?
Place a small, rolled towel under the client’s right or left hip.
211
Where should the nurse assess for fetal heart tones in a vertex presentation?
Below the client’s umbilicus in either the right or left-lower quadrant of the abdomen.
212
Where should the nurse assess for fetal heart tones in a breech presentation?
Above the client’s umbilicus in either the right or left-upper quadrant of the abdomen.
213
When does a fetus receive more oxygen during labor?
During the period of relaxation between uterine contractions.
214
What is the normal baseline FHR at term?
110 to 160/min.
215
Fetal tachycardia is defined as a FHR greater than _____ for 10 minutes or longer.
160/min
216
Fetal bradycardia is defined as a FHR less than _____ for 10 minutes or longer.
110/min
217
What is the expected or desired FHR baseline variability?
Moderate variability (6 to 25/min).
218
A Category I FHR tracing is defined by a baseline of 110-160/min, moderate variability, and the absence of _____ or _____ decelerations.
late or variable
219
What are nonreassuring FHR patterns associated with?
Fetal hypoxia.
220
What is the cause of an early deceleration of the FHR?
Compression of the fetal head.
221
What is the nursing intervention required for early decelerations?
No intervention is required, as this is a benign finding.
222
What is the primary cause of late decelerations of the FHR?
Uteroplacental insufficiency causing inadequate fetal oxygenation.
223
What is the first nursing action for a client with late decelerations on the fetal monitor?
Place the client in a side-lying position.
224
What is the primary cause of variable decelerations of the FHR?
Umbilical cord compression.
225
What is a priority nursing intervention for variable decelerations?
Reposition the client from side to side or into a knee-chest position.
226
What condition can cause minimal FHR variability and usually does not last longer than 30 minutes?
The fetal sleep cycle.
227
What are two advantages of continuous internal fetal monitoring over external monitoring?
Accurate assessment of FHR variability and accurate measurement of uterine contraction intensity.
228
What are two requirements before a continuous internal fetal monitor (scalp electrode) can be placed?
The membranes must be ruptured and the cervix must be adequately dilated (minimum 2 to 3 cm).
229
A client using patterned breathing reports numbness and tingling of the fingers. The nurse should have the client do what?
Breathe into their cupped hands or a paper bag.
230
What is the first maneuver of Leopold maneuvers designed to identify?
It identifies the fetal part occupying the fundus, which determines the fetal lie and presenting part.
231
The second maneuver of Leopold maneuvers validates the presenting part by palpating what?
The smooth contour of the fetal back on one side and the irregular small parts (hands, feet) on the other.
232
What does the third Leopold maneuver, which involves grasping the lower segment of the uterus, help identify?
It identifies the part presenting over the true pelvis inlet and assists in identifying descent.
233
The fourth Leopold maneuver, where the nurse faces the client's feet, is used to identify the fetal ____.
attitude
OB Proctor Exam ATI
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