Chapter 21 easy
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? A. Placental abruption B. Premature rupture of membranes C. Genetic abnormality D. Preeclampsia
A R:The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction? A. contractions most forceful in the middle of uterus rather than the fundus B. fetal buttocks as the presenting part C. lack of cervical dilation past 2 cm D. reports of severe back pain
A R:Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.
Before calling the primary 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 care provider? A. Make sure the client is lying on her left side. B. Check for a full bladder. C. Assess vital signs every 30 minutes. D. Make sure the epidural medication is turned down.
B R:A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.
After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do? A. Notify the physician and stop the infusion. B. Administer oral orange juice for added potassium. C. Instruct the patient to breathe in and out rapidly. D. Assess the vagina for full dilation.
A R: A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the patient during induction of labor, report them immediately and halt the infusion. Assessing the vagina for dilation, increasing respirations, and administering orange juice for potassium will not help with water intoxication.
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? A. Fetal heart tones B. Signs of shock C. Infection D. Uterine stabilization
A R: When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.
In terms of planning care, why is the development of a pathologic retraction ring important?
A pathologic retraction ring implies the uterus is stressed to its maximum; uterine rupture may follow.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
Administer oxygen by mask. R:An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.
A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? A. the 19-year-old client diagnosed with polycystic ovarian syndrome B. the 41-year-old client who conceived by in vitro fertilization C. the 38-year-old client whose spouse is a triplet D. the 27-year-old client who gave birth to twins two years ago
B R: The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.
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? A. The mother has a small pelvic opening. B. The fetus is macrosomic. C. Uterine contractions are weak and ineffective. D. The mother is fighting the contractions.
C R:Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.
The fetus of a pregnant patient is in a breech presentation. Where will the nurse auscultate fetal heart sounds?
High in the abdomen R: With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.
A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia?
magnesium sulfate R:The drug used to relax the uterine muscles and for seizure prophylaxis is magnesium sulfate. Betamethasone promotes fetal lung maturity, indomethacin inhibits uterine activity to arrest preterm labor, and nifedipine blocks calcium movement into the muscle cells and inhibits preterm labor.
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin diluted as a "piggyback" infusion. B. Administer oxytocin diluted in the main intravenous fluid. C. Administer oxytocin in two divided intramuscular sites. D. Administer oxytocin in a 20 cc bolus of saline.
A R: Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.
The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse? A. "This is true but you can receive pain medication to help relieve this." B. "Don't think so far ahead; concentrate on the problem at hand." C. "Although the birth will be dry, it won't be painful." D. "No birth is ever really dry, because amniotic fluid continues to be manufactured."
D R:The nurse should let the client know that amniotic fluid is continuously formed; no birth is ever dry. The client will be given medication for pain as well as given the option to receive an epidural at the appropriate time. The nurse should not negate the woman's concerns by telling her to not worry about it. This would be a good time for informal teaching about the process and letting the woman know the options available to assist her through this process.
The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:
4,000 g or more R:Macrosomia occurs when the fetus measures 4,000 g (8.13 lbs) or more at birth and complicates approximately 10% of all pregnancies. The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.
A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a C-section is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? A. The parents are beginning to demonstrate positive grieving behaviors. B. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn. C. The parents just cannot believe their perfect infant died. D. Parents continue to mourn the loss of their infant.
A R:An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able to give birth to a healthy child. Some infants will die. outcome achievement might include the client begins positive grieving behaviors [touching, counting toes/fingers, etc.] in response to loss of newborn. The other statements are probably accurate but are not written like outcome statements.
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? A. erratic. B. poor in quality. C. well coordinated. D. brief.
A R:Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.
The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client? A. Assess contractions by using external monitor. B. Start administering tocolytic therapy. C. Turn down oxytocin administration by half. D. Administer hydration and sedation frequently.
A R:In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.
The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider? A. 45 ml urine output in 2 hours B. hemoglobin of 13 g/dl C. platelet count of 150,000 mm3 D. hematocrit of 36%
A R:The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.
A client with full-term pregnancy who is not in active labor has been prescribed oxytocin intravenously. The nurse would notify the health care provider if which finding is noted? A. prolonged ruptured membranes B. overdistended uterus C. dysfunctional labor pattern D. postterm status
A R: Overdistended uterus is a contraindication for oxytocin administration. Postterm status, dysfunctional labor pattern, and prolonged ruptured membranes are indications for administration of oxytocin.
A client who is in labor presents with shoulder dystocia of the fetus. Which is an important nursing intervention? A. Assist with positioning the woman in squatting position. B. Assess for reports of intense back pain in first stage of labor. C. Anticipate possible use of forceps to rotate to anterior position at birth. D. Assess for prolonged second stage of labor with arrest of descent.
A R: The nurse caring for the client in labor with shoulder dystocia of the fetus should assist with positioning the client in squatting position. The client can also be helped into the hands and knees position or lateral recumbent position for birth, to free the shoulders. Assessing for complaints of intense back pain in first stage of labor, anticipating possible use of forceps to rotate to anterior position at birth, and assessing for prolonged second stage of labor with arrest of descent are important interventions when caring for a client with persistent occiput posterior position of fetus.
Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur? A. Second stage of labor B. Fourth stage of labor C. Third stage of labor D. First stage of labor
A R:Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? A. continuing to monitor maternal and fetal status B. noting the space at the maternal umbilicus C. auscultating the fetal heart rate at the level of the umbilicus D. applying suprapubic pressure against the fetal back
A R:Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? A. Uterine rupture B. Hypertonic uterus C. Placenta previa D. Umbilical cord compression
A R:The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.
A nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply. A. indomethacin B. nitroglycerin C. atosiban D. magnesium sulfate E. nifedipine
A,C,D,E, R:Medications commonly used for tocolysis include magnesium sulfate, atosiban, indomethacin, and nifedipine. These drugs are used "off label," meaning that they are effective but have not been officially tested and developed for this purpose by the Food and Drug Administration.
A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? A. hypertonic contractions B. hypotonic contractions C. uncoordinated contractions D. Braxton Hicks contractions
B R: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.
A group of nursing students are on the L & D unit where there is a woman having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. The preceptor asks the students, "What is the highest priority fetal assessment we [the nursing staff] should focus on at this time? A. Monitor fetal blood pressure for signs of shock [low BP, high FHR]. B. Look for late decelerations on monitor which is associated with fetal anoxia. C. Monitor fetal movements to ensure they are neurologically intact. D. Monitor heart rate for tachycardia.
B R: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.
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? A. Administer amnioinfusion. B. Assess fetal heart sounds. C. Administer oxygen at 10 L/min by face mask. D. Place the woman in Trendelenburg position.
B R: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.
The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifiying the RN and primary care provider, which action should the LPN prioritize? A. Assist with Nitrazine and fern tests. B. Prepare to assist with external version. C. Apply pressure to the woman's lower back with a fisted hand. D. Include a set of piper forceps when the table is prepped.
B R: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via a cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counterpressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning.
At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? A. Bed rest and hydration at home B. Hospitalization, tocolytic, and corticosteroids C. Careful monitoring of fetal kick counts D. An emergency cesarean birth
B R:At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring in a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.
When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? A. Contact a grief counselor. B. Keep the communication lines open. C. Remove the infant quickly. D. Leave the parents alone.
B R:Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye.
The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery? A. To lessen the mother's pain B. Abnormal position of the fetal head C. The fetus is descending too slowly D. Reduce risk of complications
B R:Forceps are mechanical devices which can be used to help deliver the fetus. Although no longer used routinely they are still used in certain situations to assist with the deliver. One of those situations is when the fetus is in an abnormal position and the health care provider attempts to reposition the fetus to facilitate birth. The use of forceps is not to lessen the mother's pain or to speed up the process. The use of forceps is not without risk of complications to include perineal lacerations and injury to the fetus if done incorrectly.
A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient? A. Fluid replacement B. Oxytocin therapy C. Increasing activity D. Pain management
B R: With a prolonged descent, intravenous oxytocin may be used to induce the uterus to contract effectively. Fluid replacement, pain management, and activity will not cause the fetus to descend quicker.
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: A. 6. B. 5. C. 9. D. 7.
B R:A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.
A client is told that she is already completely effaced and 9 cm dilated, and that the fetal head is showing. Contrary to the nurse's instructions, the client begins to push. Before the primary care provider can enter the room, the woman gives birth to the baby with only the nurse in attendance. This is an example of which occurrence? A. labor dystocia B. precipitate labor C. uterine dysfunction D. protraction disorder
B R:A precipitate labor can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. Labor dystocia refers to lack of progression and there are two types: protraction and arrest. Uterine dysfunction refers to types of uterine contractions and are labeled as either hypertonic or hypotonic.
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? A. Perform artificial rupture of membranes. B. Prepare the client for a cesarean birth. C. Place the client in lithotomy position for birth. D. Administer oxytocin intravenously at 4 mU/minute.
B R:Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: A. increased risk for cord entanglement. B. potential lacerations and bleeding. C. increased risk for uterine rupture. D. damage to the maternal tissues.
B R:Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.
Which statement describes why hypertonic contractions tend to become very painful? A. More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other. B. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. C. The number of uterine contractions is very low or infrequent. D. There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation.
B R:Hypertonic contractions cause uterine cell anoxia, which is painful.
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? A. betamethasone B. magnesium sulfate C. nifedipine D. indomethacin
B R:Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent.
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? A. Offer to take pictures and footprints of the infant once it is delivered. B. Call the hospital chaplain to talk to the parents. C. Explain to her that there was probably something wrong with the infant and that is why it died. D. Recommend that she not hold the infant after it is delivered so as to not upset her more.
B R:When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death better. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best? A. Wrap the intravenous line with a cling wrap. B. Instruct the client to lie still so not to dislodge the catheter. C. Use distraction therapy. D. Maintain the client in the supine position.
C R:Many women in labor may receive intravenous fluid to maintain hydration. Distraction therapy helps the client to focus her attention on the birthing process. The woman can be out of bed with this in place. She should lie on her side as should all women in labor. Pediatric clients are upset by the site of the intravenous infusion site so the site is wrapped with a cling wrap or gauze.
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? A. aspiration B. congestive heart failure C. amniotic fluid embolism D. placental separation
C R:With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: A. administer oral orange juice for added potassium. B. instruct her to breathe in and out rapidly. C. assess the rate of flow of the oxytocin infusion. D. assess her vaginally for full dilation.
C R:A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.
A delivery room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48, pulse rate 150, mucous membranes are pale. Which interventions should be the priority for the delivery room nurse? Select all that apply. A. Call environmental services to mop up the blood. B. Assist the provider in pulling harder on the placenta to get it removed quicker. C. Apply oxygen mask at 10 L/min. D. Give the provider assistance by helping re-insert the uterus back through the cervical opening. E. Discontinue the IV oxytocin infusion.
C, E R:Because uterine inversion occurs in various degrees, the inverted fundus may lie within the uterine cavity or the vagina, or in total inversion, it may protrude from the vagina. An IV fluid line should be inserted if one is not already present (use a large-gauge needle). If a line is already in place, open it to achieve optimal flow of fluid to restore fluid volume. Administer oxygen by mask, and assess vital signs. Oxytocin, if being used, should be discontinued because it makes the uterus more tense and difficult to replace. Never attempt to replace an inversion, because handling of the uterus could increase the bleeding. Never attempt to remove the placenta if it is still attached, because this would create a larger surface area for bleeding. Blood on the floor is a very low priority at this time.
A client is 2 weeks past her due date, and her health provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply. A. The cervix is ripe. B. There is absence of eclampsia. C. The fetus is in a longitudinal lie. D. A presenting part is engaged. E. Maternal blood pressure is normal. F. Cephalopelvic disproportion is present.
C. The fetus is in a longitudinal lie. A. The cervix is ripe. D. A presenting part is engaged. R:Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin/sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.
After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? A. fetal buttocks as the presenting part B. contractions most forceful in the middle of uterus rather than the fundus C. lack of cervical dilation past 2 cm D. reports of severe back pain
D R: Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? A. Cervix dilates 2 cm per hour. B. Fetus descends 2 cm per hour. C. Fetus descends 1 cm per hour. D. Cervix dilates 1 cm per hour.
D R:A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation. If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? A. encouraging the women to change positions frequently B. administering oxytocin C. preparing the woman for an amniotomy D. providing a comfortable environment with dim lighting
D R:Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. This action is consistant with assisting a women experiencing problems with the psyche. Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). An amniotomy may be used with hypertonic uterine dysfunction to augment labor. Frequent position changes would be appropriate for a woman with persistent occiput posterior position (problem with the passenger).
A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition? A. infection B. dystocia C. hemorrhage D. macrosomia
D R:Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia are risk to the mother not the fetus.
A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth? A. assess for cleft palate B. extensive lacerations C. monitor for a cardiac anomaly D. brachial plexus assessment
D R:The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.
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 by the nurse is the best answer to this question? A. Maybe your uterus is just tired and needs a rest. B. It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow delivery of the baby. C. Maybe your baby has developed hydrocephaly and their head is too swollen. D. More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal. .
D R:Arrest of descent results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the second stage is CPD. This is the best answer. Rest should allow the uterine contractions to be more efficient. The hormones secreted during pregnancy allow ligaments to soften so bones can shift to allow delivery. Ultrasound would have previously been diagnosed prior to the onset of labor.
The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain R:Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.
A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?
External cephalic version R:External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?
Identical R:The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).
The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use first to reduce this patient's discomfort?
Massage the lower back. R:Because the fetal head rotates against the sacrum in the occiput posterior position, the patient may experience pressure and pain in the lower back because of sacral nerve compression. Applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. The patient does not need to be placed in the prone or Trendelenburg positions. Ice packs are not indicated to reduce this pain.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression. R:Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?
cesarean birth R: If the cause of the delay in dilatation is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight. R:Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births.
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
less than 3 hours R:Precipitous labor is completed in less than 3 hours.
