Intrapartum Nursing Care

Question 1

List five prodromal signs of labor the nurse might teach the client.

Answer 1

Lightening, Braxton Hicks contractions, increased bloody show loss of mucus plug, burst of energy, and nesting behaviors.

Question 2

How is true labor discriminated from false labor?

Answer 2

• True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes
• False labor: irregular rhythm, abdominal pain (not in back) that decreases with ambulation

Question 3

State two ways to determine whether the membranes have truly ruptured.

Answer 3

• Nitrazine testing: paper turns dark blue or black

- Demonstration of fluid ferning under microscope

Question 4

Are psychoprophylactic breathing techniques prescribed for use according to the stage and phase of labor?

Answer 4

No. Clients should use these techniques according to their discomfort level and should change techniques when one is no longer working for relaxation.

Question 5

Identify two reasons to withhhold anesthesia and analgesia until the midactive phase of stage 1 labor.

Answer 5

If analgesia and anesthesia are given too early, they can retard labor; if given too late, they can cause fetal distress.

Question 6

Hyperventilation often occurs in the laboring client. What results from hyperventilation, and what actions should the nurse take to relieve the condition?

Answer 6

Respiratory alkalosis occurs; it is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands

Question 7

Describe the maternal changes that characterize the transition phase of labor.

Answer 7

Irritability and unwillingness to be touched, but does not want to be left alone; nausea, vomiting, and hiccuping

Question 8

When should a laboring client be examined vaginally?

Answer 8

Vaginal examinations should be done prior to analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin.

Question 9

Define cervical effacement.

Answer 9

The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0% to 100%, or complete effacement.

Question 10

Where is the FHR best heard?

Answer 10

Through the fetal back in vertex, OA positions

Question 11

Normal FHR during labor is___.

Answer 11

110 to 160 bpm

Question 12

Normal maternal BP during labor is___.

Answer 12

<140/90

Question 13

Normal maternal pulse during labor is____.

Answer 13

<100 bpm

Question 14

Normal maternal temperature during labor is___

Answer 14

<100.4 F

Question 15

List four nursing actions for the second stage of labor.

Answer 15

1. Make sure cervix is completely dilated before pushing is allowed
2. Assess FHR with each contraction
3. Teach woman to hold breath for no longer than 10 seconds
4. Teach pushing technique

Question 16

List three signs of placental separation.

Answer 16

1. Gush of blood
2. Lengthening of cord
3. Globular shape of uterus

Question 17

When should the postpartum dosage of oxytocin (Pitocin) be administered? Why is it administered?

Answer 17

Give immediately after placenta is delivered to prevent postpartum hemorrhage and atony

Question 18

State one contraindication to the use of ergot drugs (Methergine).

Answer 18

Hypertension

Question 19

State five symptoms of respiratory distress in the newborn.

Answer 19

Tachypnea, dusky color, flaring nares, retractions, and grunting

Question 20

If meconium was passed in utero, what action must the nurse take in the delivery room?

Answer 20

Arrange for immediate endotrachial tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis and meconium aspiration syndrome)

Question 21

What is considered a good Apgar score?

Answer 21

7 to 10

Question 22

What is the purpose of eye prophylaxis in the newborn?

Answer 22

To prevent opthalmia neonatorum, which results from exposure to gonorrhea in the vagina

Question 23

What is the danger associated with regional blocks?

Answer 23

Hypotension resulting from vasodilation below the block, which pools blood in periphery, reducing venous return

Question 24

What is the major cause of maternal death when general anesthesia is administered?

Answer 24

Aspiration of gastric contents

Question 25

Why are PO medications avoided in labor?

Answer 25

Gastric activity slows or stops in labor, decreasing absorption from PO route; it may cause vomiting

Question 26

State the best way to administer IV drugs during labor.

Answer 26

At the beginning of contraction, push a little medication in while uterine blood vessels are constricted, thereby reducing dose to fetus.

Question 27

When is it dangerous to administer butorphanol (Stadol), an agonist/antagonist narcotic?

Answer 27

When the client is an undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms.

Question 28

Hypotension commonly occurs after the laboring client receives a regional block. What is one of the first signs the nurse might observe?

Answer 28

Nausea

Question 29

State three actions the nurse should take when hypotension occurs in a laboring client.

Answer 29

• Turn client to left side
• Administer O2 by mask at 10 L/min
• Increase speed of intravenous infusion (if it does not contain medication)

Question 30

How is the fourth stage of labor defined?

Answer 30

The first 1 to 4 hours after delivery of placenta.

Question 31

What actions can the nurse take to assist in preventing postpartum hemorrhage?

Answer 31

Massage the fundus (gently) and keep the bladder emptied.

Question 32

To promote comfort, what nursing interventions are used for a third-degree episiotomy that extends into the anal sphincter?

Answer 32

Ice pack, which hazel compresses, and no rectal manipulation

Question 33

What nursing interventions are used to enhance maternal-infant bonding during the fourth stage of labor?

Answer 33

Withhold eye prophylaxis for up to 1 hour. Perform newborn admission and routine procedures in room with parents. Encourage early initiation of breastfeeding. Darken room to encourage newborn to open eyes.

Question 34

List three nursing interventions to ease the discomfort of afterpains.

Answer 34

• Keep bladder empty.
• Provide a warm blanket for abdomen.
• Administer analgesics prescribed by health care provider.

Question 35

List the symptoms of a full bladder that might occur in the fourth stage of labor.

Answer 35

Fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine atony)

Question 36

What action should the nurse take first when a soft, boggy uterus is palpated?

Answer 36

Perform fundal massage

Question 37

What are the symptoms of hypovolemic shock?

Answer 37

Pallor, clammy skin, tachycarda, lightheadedness, and hypotension

Question 38

How often should the nurse check the fundus during the fourth stage of labor?

Answer 38

Every 15 minutes for 1 hour; every 30 minutes for 2 hours if normal