Intrapartum care, Immediate newborn care NCLEX Questions

Intrapartum care, Immediate newborn care NCLEX Questions 5.0 (2 reviews) Students also studied Terms in this set (178) Science MedicineObstetrics Save

M4: Postpartum Assessment

Teacher 49 terms Maggie-Eastwood Preview Labor & Delivery Saunders NCLEX q...80 terms Preview NCM 109 Care of Mother & Child at-...50 terms lilpigboiPreview Intrapa 55 terms mim A pregnant woman, multipara, has been in labor for several hours. She cries out that her contractions are getting harder and that she cannot do this. The client is really irritable, nauseated, annoyed, and fearful of being left alone. Considering the client's behavior, the nurse would expect the cervix to be dilated how many centimeters?

• 3 to 5
• 0 to 2
• 5 to 6
• 8 to 10
• 8 to 10

The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?

• A woman should be left entirely alone during this

period.

• A woman will rarely speak or laugh during this period.
• A woman may spend time thinking about what is

happening to her.

• No nursing care is needed to be done during this time.
• A woman may spend time thinking about what is happening to her.

Women need a support person with them during all stages of labor.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

• allowing the woman time to be alone
• promoting the woman's feelings of control
• providing clear information about procedures
• encouraging the woman to use relaxation techniques
• allowing the woman time to be alone

Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope.Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion.Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

• shoulders
• buttocks
• brow
• occiput
• occiput

With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.A nurse is caring for a client in her third stage of labor.Which findings would the nurse assess as indicating placental separation? Select all that apply.

• fresh gushing of blood from the vagina
• a relaxed and distended uterus
• umbilical cord descending lower down
• renewed bearing down efforts by client
• falling downward of uterus in the abdomen
• fresh gushing of blood from the vagina
• umbilical cord descending lower down
• renewed bearing down efforts by client

The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and renewed bearing-down efforts by the client. When the client is in her third stage of labor, these indicate placental separation. A rising upwards of the uterus and a well-contracted globular uterus are the other signs of placental separation. Falling downward of the uterus in the abdomen and a relaxed uterus are the signs of uterine atony.A nurse is caring for a pregnant client at her 34-week checkup. The client has chosen the Lamaze method for her birthing plan but states that her partner does not agree. The client says she will just change her plan. Which response by the nurse would be appropriate to support the female client?

• "Have you and your partner discussed what his / her

role will be in the birth?"

• "Just wait until the birth; your partner's mind could

change."

• "Preparing for the birth works for some clients, but not

for all."

• "Maybe you should choose a different support

person."

• "Have you and your partner discussed what his / her role will be in the birth?"

The nurse should explain to the client the different roles the partner can take in the birth process. The nurse should encourage the client to discuss both her feelings and her partner's feelings to better understand the partner's disapproval of Lamaze. This could help improve family communication. The other three answers are not therapeutic because they ignore the client's concern and do not help to prepare the client.

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?

• increase in frequency of the contractions
• irregularity in the duration of the contractions
• lessening of the contractions with position change
• decrease in the intensity of the contractions
• increase in frequency of the contractions

The nurse should identify that there is an increase in the duration of the contractions associated with true labor. In true labor, the duration, frequency, and intensity of uterine contractions increase. Position change does not reduce the uterine contractions. In false labor, the uterine contractions often disappear with ambulation and sleep. Also, there is no increase in frequency, duration, or intensity of the contractions, and the cervix fails to dilate any further.A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

• increased risk of infection
• increased risk of breech presentation
• potential placenta previa
• potential rapid birth of fetus
• increased risk of infection

After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse.The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse

documents this finding as:

• duration.
• peak.
• frequency.
• intensity.
• frequency.

Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.A pregnant client has come to the labor and birth suite in labor. The nurse reviews the client's medical record and determines that a vaginal birth is favorable based on which finding related to the client's pelvic shape?

• gynecoid
• platypelloid
• anthropoid
• android
• gynecoid

Vaginal birth is most favorable with a gynecoid pelvis because the inlet is round and the outlet is roomy. This shape offers the optimal diameters in all three planes of the pelvis. This type of pelvis allows early and complete fetal internal rotation during labor. Although vaginal birth is favorable with an anthropoid pelvis, it is less favorable than a gynecoid pelvis. However, vaginal birth is more favorable with an anthropoid pelvic shape compared with the android or platypelloid shape.A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would

be to:

• encourage the woman to breathe more slowly.
• help the woman breathe into a paper bag.
• turn the woman on her side.
• administer a sedative.
• help the woman breathe into a paper bag.

Rationale:

Just telling her to breathe more slowly does not ensure a change in respirations.The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem.Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

• Encourage her to empty her bladder.
• Decrease her intravenous (IV) rate to a keep vein-open

rate.

• Turn the woman to the left lateral position or place a

pillow under her hip.

• No action is necessary since a decrease in the

woman's blood pressure is expected.

• Turn the woman to the left lateral position or place a pillow under her hip.

Rationale:

Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion.Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate

analgesic for pain control is:

• fentanyl (Sublimaze).
• promethazine (Phenergan).
• butorphanol tartrate (Stadol).
• nalbuphine (Nubain).
• fentanyl (Sublimaze).

Rationale:

Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects.Stadol and Nubain are opioid agonist-antagonist analgesics. Their use may precipitate withdrawals in a patient with a history of opiate use.A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective

relief measure is to use:

• counterpressure against the sacrum.
• pant-blow (breaths and puffs) breathing techniques.
• effleurage.
• biofeedback.
• counterpressure against the sacrum.

Rationale:

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.Nurses should be aware of the difference experience can

make in labor pain, such as:

• sensory pain for nulliparous women often is greater

than for multiparous women during early labor.

• affective pain for nulliparous women usually is less

than for multiparous women throughout the first stage of labor.

• women with a history of substance abuse experience

more pain during labor.

• multiparous women have more fatigue from labor and

therefore experience more pain.

• sensory pain for nulliparous women often is greater than for multiparous

women during early labor.

Rationale:

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.