Chapter 18: Labor at Risk

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? McDonald maneuver McGeorge maneuver McRoberts maneuver McRonald maneuver

McRoberts maneuver

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 with the birth? To lessen the mother's pain The fetus is descending too slowly Abnormal position of the fetal head Reduce risk of complications

Abnormal position of the fetal head

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? placental separation aspiration amniotic fluid embolism congestive heart failure

Amniotic fluid embolism

A nursing student correctly identifies the most desirable position to promote an easy birth as which position? breech occiput anterior face and brow shoulder dystocia

Occiput anterior

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 dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? cesarean birth administration of oxytocin administration of morphine sulfate darkening room lights and decreasing noise and stimulation

Cesarean Birth

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? well coordinated. poor in quality. brief. erratic.

erratic.

A woman with a history of crack cocaine use disorder 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? amniotic fluid embolism shoulder dystocia uterine rupture umbilical cord prolapse

Uterine rupture

The nursing student doing a clinical obstetrics rotation correctly picks which term to label a pregnancy that continues past the end of the 42nd week of gestation? term pregnancy post-term pregnancy preterm pregnancy none of the above

Post-term pregnancy

A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in labor. To determine if the client is experiencing labor, which question(s) would be appropriate for the nurse to ask? Select all that apply. "Are you feeling any pressure or heaviness in your pelvis?" "Are you having contractions that come and go, off and on?" "Have you noticed any fluid leaking from your vagina?" "Are you having problems with heartburn?" "Have you been having any nausea or vomiting?"

"Are you feeling any pressure or heaviness in your pelvis?" "Are you having contractions that come and go, off and on?" "Have you noticed any fluid leaking from your vagina?" "Have you been having any nausea or vomiting?"

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? "This is just a normal part of labor." "Different fetal positions can cause prolonged labor and back pain." "Perhaps you have been in one position for too long." "Let me help you out of bed to try walking it off."

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

A pregnant patient at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse? "Go to the hospital now, because this could be very dangerous for the baby." "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." "You may have just passed some urine. If it were amniotic fluid, there would be much more than that." "It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."

A nurse is caring for a client who is diagnosed with a breech presentation and in the transition stage of labor. The nurse is aware that which is common at birth? A thick meconium Uterine rupture Fetal tachycardia Green tinged amniotic fluid

A thick meconium

A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next? Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis Move the client into a hands-and-knees position, to straighten the sacral curve and release the posterior shoulder Apply downward pressure above the pubic bone of the client, in an attempt to rotate the anterior shoulder Push the fetal head back into the uterus and prepare the client for cesarean birth

Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis

A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth? Assess bladder for fullness. Check perineal area frequently for bleeding. Assess the woman's breathing and intervene if necessary. Assess and administer pain medication as needed.

Check perineal area frequently for bleeding.

An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which body system does the nurse identify as a priority? respiratory genitourinary cardiovascular gastrointestinal

respiratory

The nurse provides education to a postterm pregnant client. information will the nurse include to assist in early identification of potential problems? "Increase your fluid intake to prevent dehydration." "Be sure to measure 24-hour urine output daily." "Continue to monitor fetal movements daily." "Monitor your bowel movements for constipation."

Continue to monitor fetal movements daily."

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation? Decreased fetal oxygenation Increased risk for infection Increased risk for placental abruption Decreased strength of uterine contractions

Decreased fetal oxygenation

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. Administer betamethasone to mature the fetal lungs. Ask the woman to drink 32 ounces (1 L) of water. Discontinue the oxytocin infusion. Administer an IV bolus of fluids. Apply oxygen to the woman via mask at 8 to 10 L/min.

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

A client at 38 weeks' gestation 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 trial labor forceps birth vacuum extraction

External cephalic version

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? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).

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

The nurse is assessing vital signs on the client and notes a normal blood pressure along with an elevated pulse when the patient moves from a lying to a standing or sitting position. What would this indicate? Delayed labor Overhydration Arrested labor Low fluid volume

Low fluid volume

What terminology would the nurse use to document a newborn who weighs 4,000 grams (8.8 lb) or more at birth? microsomia macrosomia meconium hydrocephalus

Macrosomia

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? Explain to her that there was probably something wrong with the infant and that is why it died. Offer to take pictures and footprints of the infant once it is delivered. Call the hospital chaplain to talk to the parents. Recommend that she not hold the infant after it is delivered so as to not upset her more.

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

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? Hold all explanations until after the birth to conserve the woman's energy. Limit discussing things the woman asks questions about. Provide ongoing communication about what is happening. Tell her not to feel anxious or discouraged about what is happening.

Provide on going communication about what is happening

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? Bradypnea Sudden shortness of breath Bradycardia Unrelieved pain

Sudden shortness of breath

A patient in labor has been prescribed an intravenous infusion of 5% dextrose/water. Following insertion of the intravenous line, what should the nurse instruct the patient to do? Try to forget the fluid line is in place. Lie on the back to allow optimal flow. Not to get out of bed once the needle is in place. Lie perfectly still so as not to dislodge the needle.

Try to forget the fluid line is in place.

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? Increase the oxytocin. Turn off the oxytocin. Increase the methotrexate. Turn off the methotrexate.

Turn off the oxytocin

A pregnant woman at the emergency department informs staff that she is at least 2 weeks past her due date. The physician begins to perform several tests to determine fetal age. The nurse anticipates that the woman's amniotic fluid volume will be decreased. How would the nurse measure the amniotic fluid in this situation? x-ray ultrasound aspiration palpation

Ultrasound

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? Place the client supine with the head of bed elevated 30 degrees. Use a fist to apply counterpressure to the lower back. Apply a warm washcloth to the lower back. Have the health care provider administer a pudendal block.

Use a fist to apply counterpressure to the lower back.

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? sedatives tocolytics uterine stimulants corticosteroids

Uterine stimulants

The nurse is assisting a primipara in the second stage of labor. The mother has been pushing now for almost 3 hours. The nurse should anticipate planning for: an operative delivery. augmentation with oxytocin. an increase in the epidural medication. a variation in pushing technique.

an operative delivery.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction? lack of cervical dilation past 2 cm fetal buttocks as the presenting part reports of severe back pain contractions most forceful in the middle of uterus rather than the fundus

contractions most forceful in the middle of uterus rather than the fundus

A nursing instructor highlights which risk factors associated with preterm labor? Select all that apply. history of previous preterm birth current multiple gestation pregnancy weight of fetus uterine or cervical abnormalities weight of pregnant mother

history of previous preterm birth current multiple gestation pregnancy uterine or cervical abnormalities

A client is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this client? oxytocin therapy fluid replacement pain management increasing activity

oxytocin therapy

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant? ability to arch the eyebrows patent airway ability to swallow fluids palpation of the anterior fontanels (fontanelles)

patent airway

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to: place a hand gently on the fetal head to guide birth. ask her to push with the next contraction so birth is rapid. assess blood pressure and pulse to detect placental bleeding. attach a fetal monitor to determine fetal status.

place a hand gently on the fetal head to guide birth.

The nurse is assisting with a vaginal birth. The client 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 umbilical cord prolapse nuchal cord breech position

shoulder dystocia

A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose? today at 2200 tomorrow at 0800 tomorrow at 1200 tomorrow at 1400 tomorrow at 1800

tomorrow at 1400

A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been ruled out. Which response(s) by the nurse would be appropriate? Select all that apply. "Maybe dimming the lights or some soft music will help you relax a bit." "Let me leave you alone for a little while so you can get some rest." "I will keep you updated often on how you and your baby are doing." "Things are moving along but sometimes it can take a little longer." "I will have to stop giving you pain medicine because it is slowing your labor."

"Maybe dimming the lights or some soft music will help you relax a bit." "I will keep you updated often on how you and your baby are doing." "Things are moving along but sometimes it can take a little longer."

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? "Maybe your uterus is just tired and needs a rest." "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." "Maybe your baby has developed hydrocephaly and the head is too swollen." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

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

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." "Transverse lie is the same as when the shoulder presents to the birth canal." "Breech presentation is when the fetal buttocks present to the birth canal." "In most pregnancies at term the fetus presents head down."

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

Although many women envision a plan of how labor will go, sometimes complications happen, and their plan is no longer achievable. When this happens, what is the best question the nurse can ask the woman at this time? "Do you think your baby knows how you wanted your labor to progress?" "What do you consider your primary goal for the outcome of this pregnancy?" "Have you ever had your plans changed in the middle of the project?" "How do you handle events that do go your way?"

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

The nurse is requested to assist the physician with an external version. What intervention should the nurse perform prior to and immediately after the external version? A nonstress test An electrocardiogram Administer tocolytics Administer an opioid analgesic

A nonstress test

When premature rupture of membranes (PROM) occurs and labor does not commence within 24 hours, the patient is usually placed on bed rest with pelvic rest. What is pelvic rest? Disintegrating vessels Frequent ultrasound examinations A situation where nothing is placed in the vagina. A dry cord

A situation where nothing is placed in the vagina.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: administer oxygen by mask. increase her intravenous fluid infusion rate. put firm pressure on the fundus of her uterus. tell the woman to take short, catchy breaths.

Administer oxygen by mask

Which action(s) will the nurse take when asked to apply suprapubic pressure during a birth with shoulder dystocia? Select all that apply. Apply downward pressure just above the pubic bone. Apply pressure between contractions. Apply pressure at an angle toward the face of the fetus. Apply pressure with the contractions. Apply downward pressure on the fundus of the uterus.

Apply downward pressure just above the pubic bone. Apply pressure between contractions. Apply pressure at an angle toward the face of the fetus.

A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? applying a heating pad to the back applying ice to the back applying counterpressure to the back performing acupuncture on the back

Applying counterpressure to the back

During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed. Administer oxytocin to increase the contractions.

Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed.

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. Allow the couple to spend as much time as they want with their stillborn infant. Give the parents a lock of the infant's hair. Assist the family in making arrangements for their stillborn infant.

Avoid any discussion of the situation with the couple

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? applying suprapubic pressure against the fetal back continuing to monitor maternal and fetal status noting the space at the maternal umbilicus auscultating the fetal heart rate at the level of the umbilicus

Continuing to monitor maternal and fetal status

During their experience in labor & delivery, a group of nursing students are observing a woman who is having uncoordinated contractions where the monitor shows some contractions close together, followed by a long period without any contractions. The nurse asks the students, "Which medication may help to stimulate a more effective, consistent pattern of contractions?" Which medication would be considered the best answer? morphine sulfate betamethasone terbutaline oxytocin

Oxytocin

After only 45 minutes of labor, the client feels the urge to push. She pushes once and the baby's head is visible. With the next push, the head emerges. What is the immediate risk when the head is delivered too fast? Perineal tearing Bladder incontinence Pelvic floor relaxation Vaginal stretching

Perineal tearing

A circulating nurse is preparing for a breech delivery. The critical instrument needed for this type of delivery that the nurse must include when preparing the operating table is which of the following? Different size scissors Piper forceps Large tweezers Different hemostats

Piper forceps

The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record? Precipitous labor Prolonged labor Prodromal labor False Labor

Precipitous labor

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? Administer an analgesic to the client. Prepare the client for a cesarean birth. Prepare for a precipitous vaginal birth. Prepare to assist the care provider with an amniotomy.

Prepare the client for a cesarean birth.

The nurse would prepare a client for amnioinfusion when which action occurs? Severe variable decelerations occur and are due to cord compression. Fetal presenting part fails to rotate fully and descend in the pelvis. The fetus shows abnormal fetal heart rate patterns. Maternal pushing is compromised due to anesthesia.

Severe variable decelerations occur and are due to cord compression.

A client with a pendulous abdomen and uterine fibroid tumors has 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 anterior fetal position cephalic presentation occipitoposterior position

Transverse lie

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. The nurse should immediately check the client for: amniotic fluid infection. amniotic fluid embolus. umbilical cord prolapse. placental abruption (abruptio placentae).

Umbilical cord prolapse

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? The fetus is macrosomic. The mother is fighting the contractions. The mother has a small pelvic opening. Uterine contractions are weak and ineffective.

Uterine contractions are weak and ineffective.

The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds? low in the abdomen left lateral abdomen high in the abdomen right lateral abdomen

high in the abdomen

A patient who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the patient that pelvic rest involves which of the following? staying in bed at all times placing nothing in the vagina staying in bed with bathroom privileges staying off of the feet the majority of the day

placing nothing in the vagina

A patient who is at 7 months' gestation presents to the emergency department with reports of a large gush and continuous leaking of fluid from her vagina. She does have some slight pelvic pressure but denies any contractions. This patient is showing clinical signs of which of the following? precipitous labor premature rupture of membranes dystocia all of the above

premature rupture of membranes