Chapter 21 Nursing Management of Labor and Birth at Risk

16. The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? A) 11 B) 8 C) 6 D) 3

A) 11 The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11 would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.

25. A group of nursing students are reviewing information about cesarean birth. The students demonstrate understanding of the information when they identify which of the following as an appropriate indication? (Select all that apply.. A) Active genital herpes infection B) Placenta previa C) Previous cesarean birth D) Prolonged labor E) Fetal distress

A) Active genital herpes infection B) Placenta previa C) Previous cesarean birth E) Fetal distress The leading indications for cesarean birth are previous cesarean birth, breech presentation, dystocia, and fetal distress. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or abruptio placentae), previous classic uterine incision or scar, gestational hypertension, diabetes, positive HIV status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress.

14. A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important? A) Determining an accurate gestational age B) Asking her about the occurrence of contractions C) Checking for spontaneous rupture of membranes D) Measuring the height of the fundus

A) Determining an accurate gestational age Incorrect dates account for the majority of prolonged or postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.

19. After teaching a group of nursing students about tocolytic therapy, the instructor determines that the teaching was successful when they identify which drug as being used for tocolysis? (Select all that apply.) A) Nifedipine B) Terbutaline C) Dinoprostone D) Misoprostol E) Indomethacin

A) Nifedipine B) Terbutaline E) Indomethacin Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), terbutaline (Brethine, a beta-adrenergic), indomethacin (Indocin, a prostaglandin synthetase inhibitor), and nifedipine (Procardia, a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. Dinoprostone and misoprostol are used to ripen the cervix.

24. The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. Which findings would the nurse most likely assess? (Select all that apply.) A) Significant difficulty breathing B) Hypertension C) Tachycardia D) Pulmonary edema E) Bleeding with bruising

A) Significant difficulty breathing C) Tachycardia D) Pulmonary edema E) Bleeding with bruising The clinical appearance is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest.

26. A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which of the following? A) Uterine hyperstimulation B) Headache C) Blurred vision D) Hypotension

A) Uterine hyperstimulation A major adverse effect of the obstetric use of Cytotec is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Headache, blurred vision, and hypotension are associated with magnesium sulfate.

11. A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure? A) Youll need to stay in bed while youre having this procedure. B) Well give you an analgesic to help reduce the pain. C) After the infusion, youll be scheduled for a cesarean birth. D) A suction cup is placed on your babys head to help bring it out.

A) Youll need to stay in bed while youre having this procedure. An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.

13. A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45 mL/hour D) Alert level of consciousness

B) Diminished deep tendon reflexes Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.

2. A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A) A low-lying placenta B) Fetopelvic disproportion C) Contraction ring D) Uterine bleeding

B) Fetopelvic disproportion The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.

3. The nurse would be alert for possible placental abruption during labor when assessment reveals which of the following? A) Macrosomia B) Gestational hypertension C) Gestational diabetes D) Low parity

B) Gestational hypertension Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.

15. After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) Holding a pillow against my incision will help me when I cough. B) Im going to have to wait a few days before I can start breast-feeding. C) I guess the nurses will be getting me up and out of bed rather quickly. D) Ill probably have a tube in my bladder for about 24 hours or so.

B) Im going to have to wait a few days before I can start breast-feeding. Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.

22. A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which of the following would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? A) Aging of the placenta B) Increased amniotic fluid volume C) Meconium aspiration D) Cord compression

B) Increased amniotic fluid volume Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. All of these conditions predispose this fetus to birth trauma or a surgical birth. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths (Beacock, 2011). As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult (Caughey & Butler, 2010).

23. A group of nursing students are reviewing information about methods used for cervical ripening. The students demonstrate understanding of the information when they identify which of the following as a mechanical method? A) Herbal agents B) Laminaria C) Membrane stripping D) Amniotomy

B) Laminaria Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical ripening. Herbal agents are a nonpharmacologic method. Membrane stripping and amniotomy are considered surgical methods.

10. When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A) One who has undergone a previous myomectomy B) One who had a previous cesarean birth via a low transverse incision C) One who has a history of a contracted pelvis D) One who has a vertical incision from a previous cesarean birth

B) One who had a previous cesarean birth via a low transverse incision VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.

6. The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention? A) Position changes B) Pain relief measures C) Immediate cesarean birth D) Oxytocin administration

B) Pain relief measures Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.

7. A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn? A) Asphyxia B) Clavicular fracture C) Caput succedaneum D) Central nervous system injury

C) Caput succedaneum Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.

20. A nurse is assessing a pregnant woman who has come to the clinic. 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? A) Dull low backache B) Malodorous vaginal discharge C) Dysuria D) Constipation

C) Dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and intestinal cramping with or without diarrhea.

5. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A) Sedatives B) Tocolytics C) Oxytocins D) Corticosteroids

C) Oxytocins For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

18. A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which of the following would the nurse most likely include as the most common problem? A) Macrosomia B) Breech presentation C) Persistent occiput posterior position D) Multifetal pregnancy

C) Persistent occiput posterior position Common problems involving the passenger include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia. as it relates to cephalopelvic disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most common malposition, occurring in about 15% of laboring women.

17. After teaching a group of nursing students about risk factors associated with dystocia, the instructor determines that the teaching was successful when the students identify which of the following as increasing the risk? (Select all that apply.) A) Pudendal block anesthetic use B) Multiparity C) Short maternal stature D) Maternal age over 35 E) Breech fetal presentation

C) Short maternal stature D) Maternal age over 35 E) Breech fetal presentation According to American College of Obstetrics and Gynecology (ACOG, 2009a), factors associated with an increased risk for dystocia include epidural analgesia, excessive analgesia, multiple gestation, hydramnios, maternal exhaustion, ineffective maternal pushing technique, occiput posterior position, longer first stage of labor, nulliparity, short maternal stature (less than 5 feet tall), fetal birth weight (more than 8.8 lb), shoulder dystocia, abnormal fetal presentation or position (breech), fetal anomalies (hydrocephalus), maternal age older than 35 years, high caffeine intake, overweight, gestational age more than 41 weeks, chorioamnionitis, ineffective uterine contractions, and high fetal station at complete cervical dilation.

9. A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect? A) Amniotic fluid embolism B) Shoulder dystocia C) Uterine rupture D) Umbilical cord prolapse

C) Uterine rupture Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.

4. Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are: A) Well coordinated B) Poor in quality C) Rapidly occurring D) Erratic

D) Erratic 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 and lack sufficient intensity to dilate and efface the cervix. Contractions of precipitous labor occur rapidly such that labor is completed in less than 3 hours.

21. A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman states that if she experiences any symptoms, she will do which of the following? A) Ill sit down to rest for 30 minutes. B) Ill try to move my bowels. C) Ill lie down with my legs raised. D) Ill drink several glasses of water.

D) Ill drink several glasses of water. If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction.

1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A) Supine B) Side-lying C) Sitting D) Kneechest

D) Kneechest Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

12. Which finding would indicate to the nurse that a womans cervix is ripe in preparation for labor induction? A) Posterior position B) Firm C) Closed D) Shortened

D) Shortened A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.

8. A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which of the following findings would require immediate intervention? A) Fetal heart rate of 150 beats/minute B) Contractions every 2 minutes, lasting 45 seconds C) Uterine resting tone of 14 mm Hg D) Urine output of 20 mL/hour

D) Urine output of 20 mL/hour Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minute. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.