Chapter 18: Labor at Risk Prep-U Maternal

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

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?

Stop the infusion immediately.

A client has been admitted to the birthing suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The primary care provider notes that the client is in hypotonic labor. What does this mean?

The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix.

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?

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

During a prenatal ultrasound, the client is discovered to have a succenturiate placenta. Following delivery of the fetus and placenta, which nursing assessment is most important?

assessment for hemorrhage

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction?

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

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

The fetus of a client in labor is determined to be in a persistent occiput posterior position. Which intervention will the nurse prioritize?

pain relief measures

A client in labor has been prescribed an intravenous infusion of 5% dextrose in water. Following insertion of the intravenous line, what should the nurse instruct the client to do?

Try to forget the fluid line is in place.

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?

Use a fist to apply counterpressure to the lower back.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation

A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes

A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache viscous vaginal discharge dysuria

A primigravida at 28 weeks' gestation comes to the clinic for a checkup. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply.

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

A woman in labor for over 12 hours has made 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 who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the client that pelvic rest involves which of the following?

placing nothing in the vagina

A client who comes to the emergency department states that they have not felt any fetal movement for several days. The health care provider cannot hear a fetal heartbeat and suspects fetal death. Once fetal death is confirmed by ultrasound, the health care provider immediately induces labor. Why is it important in this case to induce labor as soon as possible?

to prevent coagulopathy

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?

uterine rupture

The nurse is assessing a client in labor. On which complication of labor as identified within the 2030 National Health Goals will the nurse focus?

uterine rupture

A woman in labor is experiencing dysfunctional labor (hypotonic uterine dysfunction). Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer?

uterine stimulants

The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems?

"Continue to monitor fetal movements daily."

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 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?

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

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." "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 "arrest of labor." 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."

A pregnant client at 38 weeks' gestation is to undergo external cephalic version. The client asks the nurse, "What exactly will happen with this procedure?" Which response by the nurse is appropriate?

"The practitioner will gently press on your abdomen to turn your baby so the head is facing down."

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 pregnant client in labor experiences a problem with the passenger related to shoulder dystocia. The health care provider is planning to relieve it with McRoberts maneuver. The client asks the nurse, "What is going to happen when they try this?" Which response by the nurse would be appropriate?

"Your thighs will be flexed and moved away from the center of your body to open things up."

The nurse is reviewing the medical record of a woman for whom induction of labor is being considered. The nurse notes the following: Cervical dilation 4 cm Effacement 60% 0 Station Soft cervix Anterior cervical position Based on this information, which Bishop score would the nurse assign?

10

The nurse is evaluating care provided to a client giving birth to her first child. Which outcome regarding labor indicates that care has been effective?

A client achieved 4 cm of dilation after 7 hours of labor.

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?

Abnormal position of the fetal head

While the placenta is being delivered after labor, a client experiences an amniotic fluid embolism. What should the nurse do first to help this client?

Administer oxygen by nasal cannula.

A 32-year-old black woman in her second trimester has come to the clinic for an evaluation. While interviewing the client, she reports a history of fibroids and urinary tract infection. The client states, "I know smoking is bad and I have tried to stop, but it is impossible. I have cut down quite a bit though, and I do not drink alcohol." Complete blood count results reveal a low red blood cell count, low hemoglobin, and low hematocrit. When planning this client's care, which factor(s) would the nurse identify as increasing the client's risk for preterm labor? Select all that apply.

African heritage history of fibroids cigarette smoking history of urinary tract infections complete blood count results

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.

The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions?

Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min.

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

Before calling the health care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the health care provider?

Check for a full bladder.

A client arrives in the labor and delivery unit in the beginning early phase with the contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the client in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the client for which priority assessment caused by a rapid birth?

Check perineal area frequently for bleeding.

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

A pregnant client receiving intravenous oxytocin for 1 hour has contractions lasting 85 seconds. What should the nurse do first for this client?

Discontinue the oxytocin infusion.

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.

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.

The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this client's discomfort?

Massage the lower back.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRoberts maneuver

A client at 34 weeks' gestation arrives at labor and delivery after falling. The nurse writes the above notes. Based on these assessments, the nurse anticipates which plan of care for this client?

Monitor maternal/fetal status for 8 hours.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

Occiput posterior position

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.

A circulating nurse is preparing for a breech birth. The critical instrument needed for this type of delivery that the nurse must include when preparing the operating table is:

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

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?

Prepare the client for a cesarean birth.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening.

A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which finding?

Respiratory rate of 16 breaths/minute

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression.

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.

A client in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare the client for this type of delivery? Select all that apply.

Validate that the cervix is fully dilated. Determine that the client's bladder is empty. Ensure that the client's membranes have ruptured.

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments for the nursing staff. For which clients would augmentation of labor with oxytocin be contraindicated, or used cautiously? Select all that apply.

a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours a 33-year-old female who is 32 weeks' gestation in labor with twins a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider

The nurse is requested to assist the health care provider with an external cephalic version (ECV). What intervention should the nurse perform prior to and immediately after the external cephalic version?

a nonstress test

When preterm prelabor rupture of membranes (PPROM) occurs and labor does not commence within 24 hours, the client is usually placed on bed rest with pelvic rest. What is pelvic rest?

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.

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.

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 counterpressure to the back

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

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?

complications of a post-term pregnancy

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 is confirmed to be in labor. Upon examination, she is 3 cm dilated and the fetus has started to descend. Three hours after admission, however, she appears not to be progressing. She remains only 3 cm dilated, and the fetus is in the same position. The physician terms this as:

disorder of arrest.

A nurse in a hospital is caring for a 22-year-old G2P1 client who is at 32 weeks' gestation in active labor. The client calls out, "I think my water broke." The nurse at the bedside pulled back the sheet and found clear fluid with an umbilical cord in the client's vagina.

follow the hospital's cord prolapse protocol insert a hand to hold up the cord contact the health care provider. delegate tasks to other nurses

The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds?

high in the abdomen

Preterm prelabor rupture of membranes (PPROM) can be a serious complication of labor. What is the most common cause of preterm PROM?

infection

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

low fluid volume

A nurse is caring for a client at 30 weeks' gestation who had preterm premature rupture of membranes (PROM) 25 hours ago. The client has a temperature of 102°F (38.9°C) and a foul-smelling odor from the vagina. Which medication order should the nurse question?

magnesium sulfate 2 g IV/hr

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior

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

A pregnant client presents to the emergency department reporting back-to-back contractions. Within 2 hours, the client is completely effaced and 9 cm dilated, and the fetal head is showing. Within minutes the client gives birth with only the nurse in attendance. This is an example of which occurrence?

precipitate labor

A client 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 client is showing clinical signs of which of the following?

premature rupture of membranes

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating?

preterm labor

A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor?

ruptured membranes

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

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?

tocolytic therapy

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?

tomorrow at 1400

A client with a pendulous abdomen and uterine fibroids (uterine myomas) 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

A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion?

ultrasound

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?

ultrasound

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:

umbilical cord prolapse.

A client in their third trimester is being seen in the clinic with new-onset fever, lethargy, and painful urination. Vital signs: temperature, 101.2°F (38.4°C); blood pressure, 110/70 mm Hg; heart rate, 98 beats/min.

urinary tract infection (UTI) painful urination

A client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 beats/min and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

uterine rupture

A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor?

variable deceleration pattern

The nurse is examining a client at 37 weeks' gestation who came to labor and delivery with severe cramps and vaginal spotting. While listening to the fetal heart rate the nurse observes a reddened area of the side of the client's abdomen. When the nurse asks about the area, the client says "I got hit with a broom." The nurse asks who hit her, but the client does not respond. A vaginal examination reveals the cervix is 50% effaced and dilated 1 cm, membranes are intact, no bleeding and the presenting part is floating. Based on the nurse's assessment, the client is admitted to the observation unit to be monitored for which obstetrical condition?

Placental abruption (abruptio placentae)

The nurse is monitoring a client in labor who has had a previous birth via cesarean 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 the abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

A nurse is caring for a client who is a 22-year-old gravida 1 para 0 in labor. The client has been in labor for 10 hours. The nurse assesses the fetal monitor, and the client has contractions every 3 to 5 minutes, lasting 40 to 45 seconds, and are palpated moderately. The vaginal examination is completed, and the client is only 3 cm, at 60% effacement, and at -3 station. The client states that the pain level is 7 out of 10.Drag words from the choices below to fill in each blank in the following sentence. The nurse determines the client is experiencing

dystocia cervical dilation at 3cm

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.