Ch. 23

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?

amniotic fluid embolism

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?

"Different fetal positions can cause prolonged labor and back pain."

The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5

A woman in active labor suddenly sits up, clutches her chest, screams with pain, and then collapses back on the bed. The RN notes she is unconscious and a bluish-gray color. Which interventions are considered the priority for the nurse to implement? Select all that apply.

Apply oxygen mask and start oxygen at 10 L/min. Begin CPR immediately.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

Fetal heart tones

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?

Look for late decelerations on monitor, which is associated with fetal anoxia.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?

McRoberts maneuver

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time?

Offer to take pictures and footprints of the infant once it is delivered.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus?

Shoulder dystocia

A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?

Umbilical cord prolapse

The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation. Assessment reveals prolapsed fetal cord. Which action should the nurse prioritize?

Use fingers to press upward on the presenting part.

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem?

Uterine contractions are weak and ineffective.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

knee-chest

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours

A woman in labor for over 12 hours has very little progress. The health care provider thinks that her contractions lack the force needed to propel the infant downward through the birth canal. The provider asks a group of nursing students which hormone may need to be given to increase the force of the contraction. Which hormone would be the best answer?

oxytocin, a posterior pituitary hormone

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie

A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?

uterine rupture

A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question?

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

Although many women envision a plan of how labor will go, sometimes complications happen, and their plan is no longer achieveable. When this happens, what is the best question the nurse can ask the woman at this time?

"What do you consider your primary goal for the outcome of this pregnancy?"

The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery?

Abnormal position of the fetal head

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained

A laboring woman is receiving oxytocin IV to augment her labor and 2 hours later begins having contractions every 2 minutes lasting 60 to 90 seconds each with little, if any, rest time in between the contractions. At this time, which interventions would be the priority for the nurse caring for this client? Select all that apply.

Discontinue the oxytocin infusion. Administer an IV bolus of fluids. Apply oxygen to the woman via mask at 8 to 10 L/min.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

Use McRoberts maneuver.

A woman in labor with a history of drug and alcohol addiction and no prenatal care has arrived in the emergency department in active labor with cervix 5 cm dilated. An ultrasound shows the fetus in a breech presentation. As a nurse prepares to care for this woman, which assessments indicate the fetus is in distress and needs immediate help to survive? Select all that apply

variable deceleration FHR pattern noted on monitor fetal heart rate decreasing into the 80s

A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?

Risk for fetal infection related to early rupture of membranes

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?

erratic.

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?

Prepare to assist with external version.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

Uterine rupture