The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is:
Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:
Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be:
Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:
This is the way to determine the frequency of the contractions
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:
A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:
Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:
A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:
An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.
The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:
By 36 weeks gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:
Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
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