Chapter 21: Nursing Management of Labor and Birth at Risk

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? A.) Decreased fetal oxygenation B.) Increased risk for infection C.) Increased risk for placental abruption D.) Decreased strength of uterine contractions

Answer: A.) Decreased fetal oxygenation Rationale; When there is a cord prolapse the cord becomes compressed, blood flow is interrupted, and there is decreased oxygen available to the fetus resulting in fetal distress. There is a slight increased risk for postbirth infection, but it is not the priority at this time. A cord prolapse does not increase the risk for placental abruption nor does it decrease the strength of uterine contractions.

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? A.) positioning the woman prone B.) McRoberts maneuver C.) fundal pressure D.) Lamaze position

Answer: B.) McRoberts maneuver Rationale: The McRoberts maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

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

Answer: A.) Severe variable decelerations occur and are due to cord compression. Rationale: 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; descent 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 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

Answer: A.) Uterine rupture Rationale: 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 nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? A.) administering oxytocin B.) preparing the woman for an amniotomy C.) encouraging the woman to assume a hands-and-knees position D.) providing a comfortable environment with dim lighting

Answer: A.) administering oxytocin Rationale: Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

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

Answer: B.) Sudden shortness of breath Rationale: Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.

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

Answer: B.) continuing to monitor maternal and fetal status Rationale; 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 woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: A.) administer oxygen by mask. B.) increase her intravenous fluid infusion rate. C.) put firm pressure on the fundus of her uterus. D.) tell the woman to take short, catchy breaths.

Answer: A.) administer oxygen by mask. Rationale: 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 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

Answer: A.) fetal heart tones Rationale: 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.

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? A.) less than 5 hours B.) less than 3 hours C.) less than 4 hours D.) less than 8 hours

Answer: B.) less than 3 hours

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? A.) bronchodilators B.) tocolytic therapy C.) muscle relaxants D.) anti-anxiety therapy

Answer: B.) tocolytic therapy Rationale: Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? A.) If the woman has a full bladder, labor may be uncomfortable for her. B.) If the woman's bladder is distended, it may rupture. C.) A full bladder or rectum can impede fetal descent. D.) A full rectum can cause diarrhea.

Answer: C.) A full bladder or rectum can impede fetal descent.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? A.) extensive lacerations B.) monitor for a cardiac anomaly C.) assess for cleft palate D.) brachial plexus assessment

Answer: D.) brachial plexus assessment Rationale: 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, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? A.) Late decelerations B.) Early decelerations C.) Variable decelerations D.) Mild decelerations

Answer: A.) Late decelerations Rationale: When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

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.) genetic abnormality B.) premature rupture of membranes C.) preeclampsia D.) placental abruption

Answer: D.) placental abruption Rationale: The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.

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? A.) Precipitous labor B.) Prolonged labor C.) Prodromal labor D.) False Labor

Answer: A.) Precipitous labor Rationale: A labor that is less than 3 hours in duration is a precipitous labor. Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20 hours or more in a first-time mother. Prodromal labor is labor that starts and stops before fully active labor begins. The contractions are real, but they come and go, and labor does not progress. False labor is intermittent nonproductive or practice contractions, which most commonly occur in the last 2 months before a full-term delivery.

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.) assess the rate of flow of the oxytocin infusion. B.) administer oral orange juice for added potassium. C.) assess her vaginally for full dilation (dilatation). D.) instruct her to breathe in and out rapidly.

Answer: A.) assess the rate of flow of the oxytocin infusion. Rationale: A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

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? A.) fraternal B.) identical C.) neither type results from a split ovum D.) both types can result from the split ovum

Answer: B.) identical Rationale: 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).

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? 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 birth of the baby." C.) "Maybe your baby has developed hydrocephaly and the head is too swollen." D.) "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

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

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."

Answer: - "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."

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: A.) 4,000 g to 4500 g B.) 3,500 g to 4000 g C.) 2500 to 3000 g D.) 3,000 g to 3500 g

Answer: A.) 4,000 g to 4500 g Rationale: Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? A.) Assess uterine tone to determine fundal firmness. B.) Delay breastfeeding the newborn for a day. C.) Ensure that the client does not cough or breathe deeply. D.) Avoid early ambulation to prevent respiratory problems.

Answer: A.) Assess uterine tone to determine fundal firmness. Rationale: When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

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? A.) Avoid any discussion of the situation with the couple. B.) Allow the couple to spend as much time as they want with their stillborn infant. C.) Give the parents a lock of the infant's hair. D.) Assist the family in making arrangements for their stillborn infant.

Answer: A.) Avoid any discussion of the situation with the couple. Rationale: The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? A.) Use McRoberts maneuver. B.) Use Zavanelli maneuver. C.) Apply pressure to the fundus. D.) Attempt to push in one of the fetus's shoulders.

Answer: A.) Use McRoberts maneuver. Rationale: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

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? A.) cesarean birth B.) administration of oxytocin C.) administration of morphine sulfate D.) darkening room lights and decreasing noise and stimulation

Answer: A.) cesarean birth Rationale: If the cause of the delay in dilation (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 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? A.) complications of a post-term pregnancy B.) complications of preterm labor C.) complications of placenta previa D.) placental abruption (abruptio placentae)

Answer: A.) complications of a post-term pregnancy Rationale: A post-term pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? A.) depressed deep tendon reflexes B.) tachypnea C.) bradycardia D.) elevated blood glucose

Answer: A.) depressed deep tendon reflexes Rationale: The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline.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.

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? A.) external cephalic version B.) trial labor C.) forceps birth D.) vacuum extraction

Answer: A.) external cephalic version Rationale: 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 dilation (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 woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? A.) providing a comfortable environment with dim lighting B.) administering oxytocin C.) preparing the woman for an amniotomy D.) encouraging the women to change positions frequently

Answer: A.) providing a comfortable environment with dim lighting Rationale: 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 consistent with assisting a woman 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).

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.) reports of severe back pain B.) lack of cervical dilation (dilatation) past 2 cm C.) fetal buttocks as the presenting part D.) contractions most forceful in the middle of uterus rather than the fundus

Answer: A.) reports of severe back pain Rationale: 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 (dilatation) 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.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? A.) the 41-year-old client who conceived by in vitro fertilization B.) the 38-year-old client whose spouse is a triplet C.) the 19-year-old client diagnosed with polycystic ovary syndrome D.) the 27-year-old client who gave birth to twins 2 years ago

Answer: A.) the 41-year-old client who conceived by in vitro fertilization Rationale: The nurse should assess infertility treatment as a contributor to the 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 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? A.) transverse lie B.) anterior fetal position C.) cephalic presentation D.) occipitoposterior position

Answer: A.) transverse lie Rationale: A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroids (uterine myomas) that obstruct the lower uterine segment; contraction of the pelvic brim; congenital abnormalities of the uterus; or hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelvis.

A nurse is caring for a client who is scheduled to undergo an amnioinfusion. The nurse would question this prescription if which finding is noted upon client assessment? A.) uterine hypertonicity B.) active genital herpes infection C.) blood pressure of 130/88 mm Hg D.) decreased urine output

Answer: A.) uterine hypertonicity Rationale: The nurse should ensure that the client does not have uterine hypertonicity to confirm that amnioinfusion is not contraindicated. Other factors that enforce contraindication of amnioinfusion include vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, and severe fetal distress. Active genital herpes infection is a condition that enforces contraindication of labor induction rather than amnioinfusion. Urine output and blood pressure do not determine a client's ability to receive an amnioinfusion.

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? A.) Make sure the epidural medication is turned down. B.) Check for a full bladder. C.) Make sure the client is lying on her left side. D.) Assess vital signs every 30 minutes.

Answer: B.) Check for a full bladder. Rationale: A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

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? A.) Assess bladder for fullness. B.) Check perineal area frequently for bleeding. C.) Assess the woman's breathing and intervene if necessary. D.) Assess and administer pain medication as needed.

Answer: B.) Check perineal area frequently for bleeding. Rationale: Precipitous dilation (dilatation) is cervical dilation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara. Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the perineum, placing the woman at risk for hemorrhage. The other interventions are appropriate, but the priority is assessing for bleeding/hemorrhage.

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

Answer: B.) Offer to take pictures and footprints of the infant once it is delivered. Rationale: 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. 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 G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina? A.) With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. B.) Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. C.) Place the client in Trendelenburg position and gently attempt to reinsert the cord. D.) Contact the health care provider and prepare the client for an emergent vaginal birth.

Answer: B.) Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Rationale: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.

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.) an emergency cesarean birth D.) careful monitoring of fetal movement (kick) counts

Answer: B.) hospitalization, tocolytic, and corticosteroids Rationale: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating the continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allows 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 movement (kick) counts is typically done with a postterm pregnancy.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: A.) increased risk for uterine rupture. B.) potential lacerations and bleeding. C.) increased risk for cord entanglement. D.) damage to the maternal tissues.

Answer: B.) potential lacerations and bleeding. Rationale: 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.

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

Answer: C.) "Continue to monitor fetal movements daily." Rationale: The nurse will teach the postterm client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.

The nursing student demonstrates an understanding of dystocia with which statement? A.) "Dystocia is diagnosed at the start of labor." B.) "Dystocia is not diagnosed until after the birth." C.) "Dystocia is diagnosed after labor has progressed for a time." D.) "Dystocia cannot be diagnosed until just before birth."

Answer: C.) "Dystocia is diagnosed after labor has progressed for a time." Rationale: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

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? A.) To lessen the mother's pain B.) The fetus is descending too slowly C.) Abnormal position of the fetal head D.) Reduce risk of complications

Answer: C.) Abnormal position of the fetal head Rationale: 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 birth. 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, include perineal lacerations and injury to the fetus if the forceps are not used correctly.

A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? A.) Apologize and tell her that the photos will be destroyed immediately. B.) Console her with the fact that she has other children. C.) Tell her that the hospital will keep the photos for her in case she changes her mind. D.) Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.

Answer: C.) Tell her that the hospital will keep the photos for her in case she changes her mind. Rationale: Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the birth. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

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? A.) applying a heating pad to the back B.) applying ice to the back C.) applying counterpressure to the back D.) performing acupuncture on the back

Answer: C.) applying counterpressure to the back Rationale: Counterpressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: A.) longer length of labor. B.) increased number of overall pregnancies. C.) increasing birth weight. D.) poor quality of prenatal care.

Answer: C.) increasing birth weight. Rationale: 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 as many as 2% of vaginal births.

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 in a 20 cc bolus of saline. B.) Administer oxytocin in two divided intramuscular sites. C.) Administer oxytocin diluted in the main intravenous fluid. D.) Administer oxytocin diluted as a "piggyback" infusion.

Answer: D.) Administer oxytocin diluted as a "piggyback" infusion. Rationale: Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

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.) Place the client in lithotomy position for birth. B.) Administer oxytocin intravenously at 4 mU/minute. C.) Perform artificial rupture of membranes. D.) Prepare the client for a cesarean birth.

Answer: D.) Prepare the client for a cesarean birth. Rationale: 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.

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 notifying the RN and primary care provider, which action should the LPN prioritize? A.) Include a set of piper forceps when the table is prepped. B.) Apply pressure to the woman's lower back with a fisted hand. C.) Assist with nitrazine and fern tests. D.) Prepare to assist with external version.

Answer: D.) Prepare to assist with external version. Rationale: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position using external version or be born via 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 (OP) positioning.

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

Answer: D.) contractions most forceful in the middle of uterus rather than the fundus Rationale: 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 (dilatation) 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.

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.) well coordinated. B.) poor in quality. C.) brief. D.) erratic.

Answer: D.) erratic. Rationale: 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.

A pregnant client in preterm labor is prescribed an oral tocolytic agent. Which agent does the nurse expect to be used? A.) magnesium sulfate B.) terbutaline C.) progesterone D.) nifedipine

Answer: D.) nifedipine Rationale: Nifedipine is an oral tocolytic. Magnesium sulfate is given intravenously. Terbutaline may be given intravenously or subcutaneously. Progesterone is commonly given by injection.

A 19-year-old nulliparous woman is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. The nurse suspects which complication? A.) reduced oxygen to the fetus B.) ruptured uterus C.) cephalopelvic disproportion D.) precipitate labor

Answer; A.) reduced oxygen to the fetus Rationale: Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between contractions. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. This occurs in early labor and affects nulliparous women more than multiparous women. A ruptured uterus is a potential complication; however, hypoxia to the fetus would occur first. Cephalopelvic disproportion is usually associated with hypotonic uterine dysfunction. Precipitate labor is one that is completed in less than 3 hours from the start of contractions to birth.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? A.) cervical lacerations B.) perineal hematoma C.) infection of episiotomy D.) caput succedaneum

Answer; D.) caput succedaneum Rationale: Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps-assisted birth. Maternal complications include tissue trauma such as lacerations of the cervix, vagina, and perineum; hematoma; extension of episiotomy into the anus; hemorrhage; and infection.