Chapter 15 Questions
Which parameter should be closely monitored in a patient during the latent phase of the first stage of labor? 1 Fetal heart rate 2 Cervical dilation 3 Maternal temperature 4 External cephalic version
1 During the first stage of labor, uterine contractions have just begun and the fetus is monitored for various parameters. The fetal heart rate is monitored at least every 30 to 60 minutes to ensure the safety of the fetus. Cervical dilation is assessed through vaginal examination and helps to determine the approximate time required for delivery. Maternal temperature is monitored every 2 to 4 hours to ensure the patient's safety. External cephalic version is performed to align the fetus to the birth canal.
A pregnant patient is administered terbutaline (Brethine). The nurse reports to the primary health care provider that the patient has a heart rate of 134 beats per minute and blood pressure of 80/60 mm Hg. Which intervention would be helpful in preventing complications related to terbutaline (Brethine)? 1 Administer propranolol (Inderal). 2 Monitor serum potassium levels. 3 Administer 1 g calcium gluconate. 4 Assess for the presence of oligohydramnios.
1 Terbutaline (Brethine) is a tocolytic agent that is used in the treatment of preterm labor. A heart rate of 134 beats per minute (tachycardia) combined with blood pressure that is less than 80/60 mm Hg indicates intolerable adverse effects of the drug on the cardiovascular system. Propranolol (Inderal) is administered to reverse the cardiovascular adverse effects of terbutaline (Brethine). Serum potassium levels should be monitored in the patient receiving terbutaline (Brethine). However, it is not a priority intervention. Calcium gluconate is administered to reverse the effects of magnesium sulfate. Oligohydramnios (low amniotic fluid volume) is the adverse effect of indomethacin (Indocin) and may not be associated with terbutaline (Brethine).
The nurse is caring for a pregnant patient who has been prescribed terbutaline (Brethine) to relax the uterus. Following the assessment, the nurse informs the primary health care provider that it is not safe to administer terbutaline (Brethine) to the patient. Which patient condition leads the nurse to such a conclusion? 1 Blood pressure of 80/60 mm Hg 2 Short episode of hyperglycemia 3 Irregular episodes of dysrhythmias 4 Heart rate of less than 120 beats/minute
1 Terbutaline (Brethine) relaxes the smooth muscles and inhibits uterine activity. However, the drug can adversely affect the cardiovascular system. Presence of a blood pressure lower than 90/60 mm Hg indicates an adverse effect on the cardiovascular system, and the nurse should stop the treatment to prevent further damage. Short and irregular episodes of hyperglycemia and dysrhythmias are mild and tolerable adverse effects of terbutaline (Brethine), so those conditions would not warrant the discontinuation of the medication. If the patient develops tachycardia greater than 130 beats/minute, then the treatment should be stopped.
When assessing uterine activity, nurses should be aware of what? 1 The examiner's hand should be placed on the fundus before, during, and after contractions. 2 The frequency and duration of contractions are measured in seconds for consistency. 3 Contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together. 4 The resting tone between contractions is described as either placid or turbulent.
1 The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
Which is an abnormal finding in a fetus during labor? 1 The fetal heart rate is 190 beats/minute at term. 2 The fetal head is in a synclitic position. 3 The fetal oxygen pressure decreases. 4 The fetal circulation is decreased.
1 The normal range of fetal heart rate is 110 to 160 beats/minute at term. Therefore, 190 beats/minute is an abnormal finding in the fetus. The fetal head is usually in a synclitic position, which indicates that the head is parallel to the anteroposterior plane of the pelvis. The oxygen pressure decreases as the fetal lung fluid is cleared from the air passage during the birth process. This aids in immediate respiration after birth. The fetal circulation tends to decrease during labor because of uterine contractions
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include which actions? 1 Encouraging the woman to try various upright positions, including squatting and standing 2 Telling the woman to start pushing as soon as her cervix is fully dilated 3 Continuing an epidural anesthetic so that pain is reduced and the woman can relax 4 Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction
1 Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed if she is able). The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. What measures are included? 1 Encouraging the woman to try various upright positions, including squatting and standing 2 Telling the woman to start pushing as soon as her cervix is fully dilated 3 Continuing an epidural anesthetic so that pain is reduced and the woman can relax 4 Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction
1 Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.
The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? Select all that apply. 1 Unstable coronary artery disease 2 Previous cesarean birth 3 Placenta previa 4 Initial blood pressure of 132/87 5 History of three spontaneous abortions
1,2,3 Maternal indications for cesarean birth include: (1) specific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease); (2) specific respiratory disease (e.g., Guillain-Barré syndrome); (3) conditions associated with increased intracranial pressure; (4) mechanical obstruction of the lower uterine segment (tumors, fibroids); (5) mechanical vulvar obstruction (e.g., extensive condylomata); and (6) history of previous cesarean birth. Fetal indications for cesarean birth include: (1) abnormal fetal heart rate or pattern; (2) malpresentation (e.g., breech or transverse lie); (3) active maternal herpes lesions; (4) maternal human immunodeficiency virus with a viral load of more than 1000 copies/mL; and (5) congenital anomalies. Maternal-fetal indications include: (1) dysfunctional labor (e.g., cephalopelvic disproportion, "failure to progress" in labor); (2) placental abruption; (3) placenta previa; and (4) elective cesarean birth (cesarean on maternal request). The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth.
What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part
1,3,5 Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are in turn caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.
A primary health care provider orders an ultrasound for a pregnant patient before attempting external cephalic version (ECV). Upon assessing the patient's ultrasound report, the nurse suspects that the primary health care provider will not attempt ECV. Which findings support the nurse's expectation? Select all that apply. 1 The patient has a nuchal cord. 2 The patient is Rh negative. 3 The patient has oligohydramnios. 4 The fetal heart rate is 120 beats per minute. 5 The patient has uterine anomalies
1,3,5 ECV is performed to change the fetus from a breech to a vertex presentation by applying pressure on the abdomen. ECV is contraindicated in certain conditions, including the presence of a nuchal cord, oligohydramnios, and uterine anomalies. ECV should be avoided if the ultrasound shows any of the complications mentioned. ECV is not contraindicated in Rh-negative patient. Patients with an Rh-negative blood group are administered Rh immunoglobulin before performing ECV. A fetal heart rate of 120 beats per minute is considered normal, and ECV is not contraindicated in this condition.
A nurse is caring for a patient whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of what? 1 Uterine contractions occurring every 8 to 10 minutes 2 A fetal heart rate (FHR) of 180 with absence of variability 3 The patient needing to void 4 Rupture of the patient's amniotic membranes
2 An FHR of 180 with absence of variability is nonreassuring. The oxytocin should be immediately discontinued and the physician should be notified. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. The oxytocin should be discontinued if uterine hyperstimulation occurs. The patient needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient's membranes have ruptured.
After performing Leopold maneuvers on a patient at 38 weeks of pregnancy, the nurse concludes that the patient will require external cephalic version for having a vaginal delivery. What was the finding during assessment? 1 The patient had a short pelvic outlet. 2 The fetus is in the breech presentation. 3 The fetus had not descended in the pelvis. 4 The patient has weak uterine contractions
2 External cephalic version is an ultrasound-guided, hands-on technique that is used to externally manipulate the fetus into a cephalic lie. This technique is indicated when the fetus has a non-cephalic presentation such as breech presentation. If the patient has a short pelvic outlet, the patient must usually undergo a caesarean delivery. External cephalic version cannot be done if the fetus has not descended in the pelvis. The patient is not in labor, so the patient will have weak uterine contractions.
The nurse is conducting a focused assessment of a pregnant patient in the birthing unit. Which vital sign measurement is abnormal and should be reported to the physician? 1 Temperature 37.3°C (99.1°F) 2 Blood pressure 142/110 mm Hg 3 Fetal heart rate 140 beats/minute 4 Maternal heart rate 96 beats/minute
2 Hypertension during pregnancy is defined as a sustained blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic or higher; therefore, a blood pressure of 142/110 mm Hg should be reported to the physician. A temperature of 37.3°C (99.1°F) is a normal finding. A fetal heart rate of 140 beats/minute is a normal finding. A maternal heart rate of 96 beats/minute is a normal finding
The nurse is preparing the hook for an amniotomy. Which action does the nurse take to prepare the package? 1 Leaving the package sealed 2 Partially opening the package 3 Removing the hook from the package 4 Removing one side of the package, allowing the hook to lie on the other side
2 Preparation of the hook for amniotomy includes partially opening the package so that the provider can remove the hook from the sleeve in a sterile fashion. The package is not left sealed, completely opened, or removed from the package.
The nurse is assigned to a patient in labor in the birth center. Nursing interventions aimed at helping the patient cope with labor should be implemented after observing which sign of ineffective coping? 1 The patient states, "I can do this." 2 The patient requests epidural anesthesia. 3 The patient has rhythmic breathing patterns. 4 The patient closes her eyes and rests between contractions.
2 Specific requests for medication and other pain control measures such as epidural anesthesia suggest the patient may not be coping with labor. The patient stating, "I can do this," rhythmic breathing patterns, and resting and relaxing between contractions are signs of coping.
A patient is expressing concern to the nurse about experiencing pain and discomfort during labor. To assist the patient in planning her labor, the nurse educates the patient about different positions of comfort. Which patient statement demonstrates that teaching was effective? 1 "Lying flat on my back is the best position to avoid pain during labor." 2 "Standing will allow the baby to descend down into my pelvis during labor." 3 "The semi-sitting position will eliminate all pain and discomfort during labor." 4 "Walking around the unit will prolong labor and possibly decrease blood flow to the baby.
2 Standing adds gravity to the force of contractions to promote fetal descent, and contractions will be less uncomfortable and more efficient. Lying flat or supine should be avoided to prevent a decrease in blood flow. Pain is expected and has a purpose in labor and cannot be completely eliminated. Ambulating and frequent position changes decrease pain, improve maternal-fetal circulation, and decrease the length of labor.
The nurse encourages a patient to experiment with various positions during labor. What is the rationale behind this instruction? 1 To enhance gas exchange in the fetus 2 To assist downward movement of the fetus 3 To reduce anxiety and fear in the patient 4 To prevent cervical and vaginal lacerations
2 The patient is encouraged to experiment with various positions during the process of labor to help the labor progress and to remain comfortable. Certain maternal positions help improve placental sufficiency more than others. These help hasten the process of vaginal delivery. To enhance gas exchange in the fetus, the patient is asked to take deep, cleansing breaths. Experimenting with various positions does not aid in effective breathing. Anxiety and fear are common during the process of labor, but this intervention may not reduce anxiety in the patient. The patient is made to feel comfortable by minimizing distractions during labor. Changing of positions may not help in preventing lacerations sustained during the childbirth process.
The nurse is caring for a newborn after a vacuum-assisted birth. What changes should the nurse monitor in the newborn? Select all that apply. 1 Inability to pass urine 2 Yellow discoloration of skin 3 Listlessness 4 Poor sucking patterns 5 Difficulty breathing
2,3,4 After a vacuum-assisted birth, the newborn might be at the risk of hyperbilirubinemia as the bruising resolves, which may cause neonatal jaundice. So the nurse should monitor the newborn for yellow discoloration of the skin. A vacuum-assisted birth may cause cerebral irritation in the newborn, which manifests as listlessness and poor sucking. Inability to pass urine may indicate structural anomalies and may not be due to vacuum delivery. Difficulty in breathing can be caused by many factors and not necessarily due to vacuum delivery.
While caring for a patient in labor, the nurse cleans the patient's teeth with an ice-cold wet washcloth. What is the rationale behind the intervention? Select all that apply. 1 To aid in relaxation 2 To refresh the mouth 3 To reduce the feeling of thirst 4 To reduce the risk of infection 5 To counteract dry mouth
2,3,5
The nurse is performing Leopold maneuvers in a patient who is in the first stage of labor. What information does the nurse obtain while performing these maneuvers? Select all that apply. 1 The fetal heart rate 2 The fetal part in the fundus 3 The tone of the uterus 4 The presenting part of the fetus 5 The descent of the fetus into the pelvis
2.4.5 Leopold maneuvers, or abdominal palpation, during the first stage of labor help determine the fetal part present in the fundus, which indicates the fetal lie. The presenting part of the fetus would help determine if the patient should undergo vaginal birth or requires a cesarean delivery. The position and location of the fetal back helps to determine the descent of the fetus into the pelvis, which indicates the approximate time required for vaginal delivery. The fetal heart rate can only be auscultated using a Doppler ultrasound. However, using abdominal palpation, the point of maximum intensity of the fetal heart rate can be determined. The nurse may not assess the tone of the fundus during the first stage of labor. The tone of the fundus is assessed after the delivery of the child to determine the risk of postpartum hemorrhage.
The nurse has witnessed a patient in the birth center experiencing spontaneous rupture of membranes (SROM). The nurse begins assessing the fetal heart rate (FHR) after SROM. What finding does the nurse report to the physician immediately as a sign of cord compression? 1 Variable accelerations 2 Prolonged accelerations 3 FHR of 90 beats/minute 4 FHR of 130 beats/minute
3 A bradycardic FHR of 90 beats/minute is a sign of cord compression after SROM and must be reported to the physician immediately. Variable accelerations and prolonged accelerations are not signs of cord compression after SROM. An FHR of 130 beats/minute is within normal limits.
The labor and delivery nurse is conducting a database assessment for a pregnant patient in the birth center. The patient's partner is present at the time of the assessment. Which part of the assessment should the nurse defer at this time? 1 Complementary therapy 2 Prescription medications 3 Risk for domestic violence 4 Pain management methods
3 Assessment of risk or history of domestic violence should only be assessed when the patient is alone for confidentiality, safety, and accuracy. It is acceptable to ask about complementary therapy, assess prescription medications, and discuss pain management methods in the presence of the partner.
The nurse is assessing a pregnant patient who has a history of migraine headaches. Which tocolytic agent is contraindicated in the patient? 1 Nifedipine (Adalat) 2 Evening primrose oil 3 Terbutaline (Brethine) 4 Magnesium sulfate (Epsom salts)
3 Beta2-adrenergic agonists like terbutaline (Brethine) are contraindicated in patients with migraine headaches because these drugs may increase the episodes of migraine. Nifedipine (Adalat) is contraindicated in hypertensive patients, but not in patients with migraine. Evening primrose oil and magnesium sulfate (Epsom salts) are tocolytic agents used to reduce oxytocin (Pitocin) usage, and are not contraindicated in patients with migraine headaches.
The nurse documents in a patient's medical record a yellow, cloudy, and foul-smelling fluid after spontaneous rupture of membranes in the birth center. What condition does this documentation describe? 1 Polyhydramnios 2 Oligohydramnios 3 Chorioamnionitis 4 Abruptio placentae
3 Chorioamnionitis is inflammation of the amniotic sac and typically presents with fluid with a foul or strong odor, cloudy appearance, or yellow color. Polyhydramnios describes an excessive volume of amniotic fluid. Oligohydramnios describes an abnormally small quantity of amniotic fluid. Abruptio placentae is a condition in which the placenta partially separates from the implantation site.
The nurse says, "You are doing so well; do it again" to a patient during the second stage of labor. Why did the nurse say this? 1 To promote comfort and minimize distractions 2 To promote bearing-down efforts in the patient 3 To encourage the patient to feel confident 4 To promote adequate oxygen levels in the fetus
3 During the second stage of labor, the patient experiences severe pain, fear, anxiety, and confusion. The patient might scream during the active pushing stage. Therefore, the nurse encourages the patient to feel confident in her body. The nurse dims the lights during labor and speaks quietly in order to comfort the patient and to minimize distractions. Once the patient gains confidence, the bearing-down effort improves. Adequate oxygen levels in the maternal blood can be maintained by asking the patient to take rapid breaths.
The nurse creates a care plan for a patient with an expected outcome to promote normal placental function. What does the nurse perform next to achieve this outcome? 1 Advises the patient to remain supine during labor 2 Reports the meconium-stained amniotic fluid to the provider 3 Places a folded blanket under one hip during urine catheterization 4 Attaches the electronic fetal heart monitor and observes for decelerations
3 Maternal positioning is the primary measure for promoting placental perfusion during normal labor. To avoid the supine position during catheterization, the nurse should place a folded blanket or small pillow under one hip to maintain placental blood flow. The supine position should be avoided during labor. Reporting meconium-stained fluid to the provider is important, but it is not the next step for achieving the outcome of normal placental function. Attaching a fetal heart monitor does not promote normal placental function.
The nurse is teaching a patient about when to go to the hospital or birth center. The patient is pregnant for the first time. What instruction does the nurse give the patient? 1 "You should go to a birth center if you have contractions lasting at least 1 minute." 2 "You should go to the hospital if you have a trickle of fluid from the vagina with contractions." 3 "Get to a birth center if you have regular contractions 5 minutes apart lasting 1 minute for 1 hour." 4 "Go to the hospital if you are having regular contractions 10 minutes apart, lasting 1 minute for 1 hour."
3 Patient teaching for a nulliparous pregnant patient about when to enter the hospital or birth center should include having regular contractions 5 minutes apart lasting 1 minute for 1 hour. A patient having a contraction for 1 minute alone does not meet criteria for entering into a hospital or birth center, and the length between contractions is important to consider depending on the parity of the patient. A gush or trickle of fluid from the vagina should be evaluated, regardless of whether contractions are occurring. A multiparous patient having regular contractions 10 minutes apart lasting 1 minute for 1 hour should go to a hospital or birth center.
Of what should a nurse providing care to a woman in labor be aware regarding cesarean birth? 1 It is declining in frequency in the United States. 2 It is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier patients do. 3 It is performed primarily for the benefit of the fetus. 4 It can be either elected or refused by women as their absolute legal right.
3 The most common indications for cesarean birth are dangers to the fetus related to labor and birth complications. Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.
The nurse at the birthing center is educating a pregnant woman who has presented with false labor. Which statement by the patient indicates a need for further learning? 1 "I will return if my water breaks." 2 "I will return if I notice any bleeding." 3 "I will return when I have the urge to push." 4 "I will return if I experience regular contractions."
3 The patient is not encouraged to wait until labor progresses to the point of feeling the urge to push. The patient is encouraged to return if there are any concerns, any signs of complications, or when signs of true labor have started. Leaking amniotic fluid, bleeding, and regular contractions are all reasons to return to the birthing center.
The nurse in the birth center is assigned to four patients. Which patient is the priority? 1 The spouse of a patient in labor pacing in the hallway 2 A patient experiencing three contractions within 10 minutes 3 The patient grunting and yelling from her room, "The baby's coming!" 4 The patient whose baby has a fetal heart rate of 146 beats/minute after premature rupture of membranes
3 The patient yelling, "The baby's coming," and grunting is demonstrating signs of impending birth and is the priority. The spouse who is pacing in the hallway is experiencing stress as a support person during the labor process but is not the priority. A patient experiencing three contractions within 10 minutes has normal uterine activity, so she is not the priority. A fetal heart rate of 146 beats/minute is normal after premature rupture of membranes and is not the priority.
Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? 1 The healthy newborn should be taken to the nursery for a complete assessment. 2 After drying, the infant should be wrapped in a receiving blanket and given to the mother. 3 Encourage skin-to-skin contact of mother and baby. 4 The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.
3 The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. Although taking the newborn to the nursery for assessment is the practice in many facilities, it is neither evidence based nor supportive of family-centered care. Wrapping the infant in a blanket and giving him or her to the mother is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed skin to skin. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated.
The nurse educator is teaching a group of student nurses about the manifestations of true labor. Which statement by a student about true labor indicates effective learning? 1 "The fetus is usually not engaged in the pelvis." 2 "The cervix is often soft and is felt in the posterior position." 3 "Contractions become more intense with walking." 4 "Contractions are felt above the navel.
3 True labor is associated with painful contractions that become more intense as the patient walks. These contractions indicate true labor. The fetus is engaged in the pelvis during true labor. When a patient is in true labor, the cervix is becomes soft and is placed anteriorly. The fetus shows progressive change and is felt in the anterior position during true labor. For most women, the contractions of true labor are not felt above the navel but at the lower portion of the abdomen.
The nurse is caring for a newborn delivered by forceps. The mother asks the nurse why the baby has bruised cheeks. How does the nurse respond? 1 "The baby may have a bleeding disorder requiring blood testing." 2 "A small birth canal caused the pelvic bones to bruise the sides of the baby's face." 3 "This is a sign of abuse, and we will investigate all those involved in the baby's care." 4 "The forceps may have bruised the baby's delicate skin, which will resolve over time."
4 A delivery involving the use of forceps may cause redness or bruising of the head or cheeks which will resolve on its own. The bruising was not caused by a bleeding disorder, pelvic bones, or abuse.
A pregnant patient has been administered terbutaline (Brethine) as prescribed. The nurse finds that the patient has a heart rate of 140 beats/minute and complains of chest pain. What is the best nursing action in this situation? 1 Administer propanolol (Inderal). 2 Administer intravenous fluids. 3 Administer 1 g calcium gluconate. 4 Inform the primary health care provider (PHP).
4 A heart rate of 140 beats per minute and chest pain indicate that the patient is having tachycardia, which is an adverse effect of terbutaline (Brethine). Therefore the nurse should report this to the PHP to obtain further instructions on the treatment. Propanolol (Inderal) is administered to reverse the cardiovascular adverse effects of terbutaline (Brethine). However, it needs to be prescribed by the PHP. Calcium gluconate is administered to reverse the effect of magnesium sulfate. Serum potassium should be monitored in the patient receiving terbutline therapy; however, it is not a priority intervention. The patient has tachycardia and is not in a state of hypovolemic shock. Therefore intravenous fluids need not be administered to the patient.
The nurse is monitoring a pregnant patient after amniotomy. Which observation would indicate a likelihood of umbilical cord compression? 1 The fetal heart rate (FHR) confirms tachycardia. 2 The patient's vaginal drainage has a foul-smell. 3 The patient has maternal chills frequently. 4 The FHR has variable decelerations
4 Amniotomy is performed in a pregnant patient in order to rupture the membranes artificially. After the procedure, the nurse should closely monitor the FHR. Reduced FHR and variable decelerations in FHR indicate that the patient's umbilical cord is compressed. The nurse should immediately inform the primary health care provider of the patient's condition. Tachycardia or increased FHR are common manifestations observed after amniotomy. Tachycardia does not require immediate clinical action. Maternal chills and foul-smelling vaginal discharge after amniotomy indicate infection of the ruptured membranes. However, this would not be a reason to expect umbilical cord compression.
The nurse is monitoring a pregnant patient after amniotomy. Which observation would indicate a likelihood of umbilical cord compression? 1 The fetal heart rate (FHR) confirms tachycardia. 2 The patient's vaginal drainage has a foul-smell. 3 The patient has maternal chills frequently. 4 The FHR has variable decelerations.
4 Amniotomy is performed in a pregnant patient in order to rupture the membranes artificially. After the procedure, the nurse should closely monitor the FHR. Reduced FHR and variable decelerations in FHR indicate that the patient's umbilical cord is compressed. The nurse should immediately inform the primary health care provider of the patient's condition. Tachycardia or increased FHR are common manifestations observed after amniotomy. Tachycardia does not require immediate clinical action. Maternal chills and foul-smelling vaginal discharge after amniotomy indicate infection of the ruptured membranes. However, this would not be a reason to expect umbilical cord compression.
The sonographic reports of a pregnant patient reveal extreme asynclitism of the fetal head. What does the nurse conclude from this report? 1 The fetal head is parallel to the anteroposterior plane of the pelvis. 2 The patient will have a normal vaginal delivery. 3 The position of the fetal head will facilitate descent. 4 Cephalopelvic disproportion will be seen during labor.
4 Extreme asynclitism of the fetal head makes the fetus unable to descend during the birth process and causes cephalopelvic disproportion. The fetal head is parallel to the anteroposterior plane of the pelvis in a synclitic position. The patient will most probably have a cesarean delivery because extreme asynclitism indicates that the fetal head is deflected in a way that may interfere with vaginal delivery. Asynclitism, not extreme asynclitism, facilitates fetal descent, because the head is being positioned to accommodate the pelvic cavity.
Which statement is most likely to be associated with a breech presentation? 1 It is the least common malpresentation. 2 Descent is rapid. 3 Diagnosis can be made by ultrasound only. 4 It is connected with a high rate of neuromuscular disorders.
4 Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. Breech is the most common malpresentation, affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made by abdominal palpation and vaginal examination. It is confirmed by ultrasound.
The charge nurse in the birth center has identified four patients with fetuses in breech presentation due for external cephalic version (ECV). The nurse is reviewing charts and advises the nurse of which patient for whom an ECV is contraindicated? 1 Patient who had her first baby vaginally without complications 2 Patient having her first baby who experienced bleeding in the first trimester 3 Patient having twins who has delivered the first vaginally in cephalic presentation 4 Patient with identified abruptio placentae with stable vital signs and fetal heart sounds
4 Manipulation of the fetus within the uterus of the patient with abruptio placentae may cause hemorrhage, endangering both mother and fetus. ECV is not contraindicated for a patient who gave birth to her first baby vaginally, or who bled during the first trimester. ECV may be attempted after the first twin is born vaginally in a cephalic presentation.
The nurse is assigned four patients who are pregnant and have a fetus in the breech presentation. Which patient is most likely to have an external cephalic version (ECV) performed in the birth center? 1 35-week pregnant patient with no complications 2 38-week pregnant patient who had a prior cesarean birth 3 36-week pregnant patient experiencing third-trimester bleeding 4 37-week pregnant patient with a history of anxiety and depression
4 The 37-week pregnant patient is most likely to have an ECV performed because she is at least 37 weeks pregnant and has no absolute contraindications. The 35-week pregnant patient should not have an ECV performed because it is usually only attempted at 37 weeks or longer of gestation. The 38-week pregnant patient is not the most likely to have an ECV because a history of a cesarean birth is a relative contraindication. The 36-week pregnant patient experienced third-trimester bleeding, which is a contraindication for an ECV.
A patient has come to the birth center because she is having contractions. After performing a physical examination, the nurse determines that the patient's membranes are intact, and she is to be discharged home. This is the patient's first pregnancy, and she expresses frustration about knowing when she is in labor. The nurse wants the patient to be able to describe reasons to return to the birth center for evaluation before she is discharged. What does the nurse do next? 1 Performs the Leopold maneuver 2 Attaches an electronic fetal heart monitor 3 Hands the patient her discharge paperwork 4 Reviews guidelines for returning to the birth center
4 The next step in the nursing process for the patient being discharged after determining false labor is implementation by reviewing the guidelines for returning to the birth center. Performing the Leopold maneuver is an assessment technique and is not the next step in the nursing process. Attaching an electronic fetal heart monitor is not the next step in the nursing process for the patient to be discharged home. Handing the patient discharge paperwork is not the next step in the nursing process because the nurse has not implemented and evaluated teaching prior to discharge.
The nurse preceptor is training a novice nurse in the birth center. The novice nurse is assisting with oxytocin administration for induction and augmentation of labor. Which action by the novice nurse demonstrates an understanding of correct oxytocin administration? 1 The novice nurse administers oxytocin as a primary infusion. 2 The novice nurse connects the oxytocin line to the most distal port in the primary line. 3 The novice nurse sets the infusion pump at the ordered rate and decreases as appropriate. 4 The novice nurse begins and records fetal heart rate and patterns before administering oxytocin.
4 Uterine activity, fetal heart rate, and fetal heart patterns are monitored before induction for a baseline, when oxytocin is started, and throughout labor. Oxytocin should be diluted in an isotonic solution and given as a secondary infusion so it can be stopped quickly if complications develop. The oxytocin line is inserted into the primary line as close as possible to the venipuncture site (the proximal port) to limit the amount of drug infused if discontinued. Oxytocin is started slowly, increased gradually, and regulated with an infusion pump.
Upon admission to the birthing unit, the nurse conducts a focused assessment including assessment of the fetal heart rate using intermittent auscultation. Which is considered a normal category I fetal heart rate finding? 1 Regular rhythm 2 Baseline rate of 180 beats/minute 3 Absence of increases from the baseline 4 Presence of decreases from the baseline
1 A regular rhythm is a normal finding under the category I fetal heart rate guidelines. A baseline rate of 180 beats/minute is higher than the normal baseline rate range of 110-160 beats/minute. Absence of increases from the baseline is not a normal finding under the category I fetal heart rate guidelines. Presence of decrease from the baseline is an abnormal finding and not part of the category I fetal heart rate guidelines.
Which infant has a higher possibility of sustaining a birth trauma? An infant who: 1 Was delivered by a vaginal birth 2 Has low glucose levels at birth 3 Has inborn errors of metabolism 4 Was born to a patient with a urinary tract infection
1 A vaginal birth increases the chance of injuries due to the use of forceps or vacuum extraction or from pressure of the fetal skull against the maternal pelvis. An infant with low glucose levels at birth is hypoglycemic. Inborn errors of metabolism refer to an inherited disease and are not a birth trauma. An infant born to a patient with a urinary tract infection has a higher chance of acquiring the infection, but this is not a birth trauma.
Which assessment finding in the patient increases the risk for a forceps assisted birth? 1 Android pelvis 2 Effacement of the cervix 3 Biparietal diameter of 9.25 cm 4 Involuntary uterine contractions (UCs)
1 An android pelvis has a narrow subpubic arch and the ischial spines have a narrow interspinous diameter. As a result, the patient will have difficulty during a vaginal birth and may require a forceps-assisted delivery. Effacement of the cervix takes place at the onset of the labor and indicates that the patient is in labor. A biparietal diameter of 9.25 cm indicates normal fetal head growth, which can be delivered vaginally. Involuntary UCs indicate that the patient is in labor.
The nurse is assessing a mother in labor. Which conditions indicate possible fetal compromise? Select all that apply. 1 Maternal fever 2 Maternal hypotension 3 Meconium-stained amniotic fluid 4 Fetal heart rate of 150 beats/minute 5 Incomplete uterine relaxation between contractions
1,2,3,5 Maternal fever may indicate infection. Maternal hypotension can malperfuse the fetus. Meconium in the amniotic fluid can indicate fetal distress. Incomplete uterine relaxation compromises blood flow to the uterus. A fetal heart rate of 150 beats/minute is normal.
Which characteristic is associated with false labor contractions? 1 Painless 2 Decrease in intensity with ambulation 3 Regular pattern of frequency established 4 Progressive in terms of intensity and duration
2 Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. True labor contractions are painful. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.
The nurse is assessing the fundus of a mother who recently delivered. The fundus is boggy. Which action should the nurse immediately take? 1 Insert a urinary catheter. 2 Have the mother bear down. 3 Massage the fundus until firm. 4 Apply cold packs to the perineum
3 A boggy fundus should be massaged until firm. Insertion of a urinary catheter may be needed if the mother cannot void on the bedpan, not if she has a boggy fundus. Bearing down is not indicated. Cold packs are needed for a hematoma, not a boggy fundus.
