Intrapartum complications Exam 1
The nurse is examining a client at 37 weeks' gestation who came to labor and delivery with severe cramps and vaginal spotting. While listening to the fetal heart rate the nurse observes a reddened area of the side of the client's abdomen. When the nurse asks about the area, the client says "I got hit with a broom." The nurse asks who hit her, but the client does not respond. A vaginal examination reveals the cervix is 50% effaced and dilated 1 cm, membranes are intact, no bleeding and the presenting part is floating. Based on the nurse's assessment, the client is admitted to the observation unit to be monitored for which obstetrical condition? A: Placental abruption (abruptio placentae) B: Preeclampsia C: Premature labor D: Placenta previa
Placental abruption (abruptio placentae) Explanation: Trauma to the abdomen increases the risk for placenta abruption (abruptio placentae). The client's presentation with severe cramps is consistent with a potential for placental abruption. A client would be monitored for preeclampsia if she presented with elevated blood pressure, proteinuria, headache, and edema of the fingers or face. The client is at 37 weeks' gestation so she is not in premature labor. A placenta previa would present with painless vaginal bleeding.
A pregnant client at 42 weeks' gestation is undergoing a scheduled induction of labor based on consideration of which factors? Select all that apply. A: abnormal fetal presentation B: cervical ripeness C: fetal size D: gestational age E: complete placenta previa
cervical ripeness fetal size gestational age Explanation: Factors that the care provider should consider when deciding if and when to induce labor include cervical ripeness, gestational age and fetal size, fetal pulmonary maturity, fetal ability to tolerate labor, uterine sensitivity to the proposed induced method, and maternal condition. The health care provider does not confirm abnormal fetal presentation and complete placenta previa when deciding to induce labor. Abnormal fetal presentation and complete placenta previa are considered contraindications to the induction of labor and not as positive factors.
A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia? A: diabetes B: preterm birth C: nullipara D: pendulous abdomen
diabetes Explanation: Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.
The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called? A: internal rotation B: external rotation C: vaginal manipulation D: external cephalic version
external cephalic version Explanation: External cephalic version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.
The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize? A: Side-lying position B: Pain relief measures C: Immediate cesarean birth D: Oxytocin administration
Pain relief measures Explanation: Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and back rubs may be helpful. Position changes that can promote fetal head rotation are important and can help to relieve some of the pain. 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.
Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation? A: General B: Regional C: Local D: Short acting
General Explanation: General anesthesia is reserved for emergencies in which the fetus must be delivered immediately to save the life of the fetus, mother or both. Regional anesthesia provides pain relief during labor and birth. Local anesthesia is typically a short-acting anesthesia used to numb the perineum.
The nurse is caring for a group of clients in labor and delivery. Which client is at greatest risk for placental abruption (abruptio placentae)? A: 28 y.o G1 at 30 weeks' gestation with a blood pressure of 150/94 and history of cigarette smoking B: 42 y.o G7P6 at 42 weeks' gestation who had limited prenatal care and has a BMI of 24 C: 30 y.o G2 at 32 weeks' gestation and a history of infertility. Her first pregnancy resulted in a stillbirth at 38 weeks D: 25 y.o. G4P3 at 38 weeks' gestation with a sedentary life style, BMI of 34, and a placenta previa
28 y.o G1 at 30 weeks' gestation with a blood pressure of 150/94 and history of cigarette smoking Explanation: Hypertension and smoking are risk factors for placental abruption (abruptio placentae). Limited prenatal care, history of infertility or stillbirth, high BMI, and placenta previa are risk factors during a pregnancy, but they do not increase the risk of placental abruption.
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
McRoberts maneuver -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 notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize? A: Turn client to her left side. B: Place client in a knee-chest position. C: Use fingers to press upward on the presenting part. D: Prep for immediate cesarean delivery.
Use fingers to press upward on the presenting part. Explanation: If the woman presents with a visible prolapse of the cord, quickly place her in bed and gently palpate the cord for pulsations to verify fetal viability. Then use fingers to press upward on the presenting part. Continue to hold the presenting part of the cord until delivery of the infant. If you discover the condition and are unable to call for help, place the client in knee-chest position, call for help, and then continue to intervene as previously described. Keeping the pressure of the fetus off the cord improves fetal circulation. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels. Turning the woman to the left side is not the intervention of choice. Another nurse will be helping prepare this client for immediate cesarean delivery.
A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. What would the nurse identify as the problem? A: Uterine contractions are too weak or uncoordinated. B: Contractions are insufficient to cause fetal descent. C: Fetus is in a different position or presentation. D: Pelvis is either android type or platypelloid type.
Uterine contractions are too weak or uncoordinated. Explanation: When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilation (dilatation). Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? A: Cord compression B: Maternal hypotension C: Maternal fatigue D: Uteroplacental insufficiency
Uteroplacental insufficiency Explanation: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
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
Late decelerations Explanation: 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 caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider? A: hematocrit of 36% (0.36) B: 45 ml urine output in 2 hours C: hemoglobin of 13 g/dl (130 g/L) D: platelet count of 150,000 mm3
45 ml urine output in 2 hours Explanation: 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.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? A: Administer oxygen. B: Increase her IV fluids. C: Change the position of the client. D: Notify the primary care provider.
Change the position of the client. Explanation: Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? A: magnesium sulfate B: nifedipine C: indomethacin D: betamethasone
magnesium sulfate Explanation: 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.
When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would be to: A: turn her to her left side. B: place her in a knee-chest position. C: replace the cord with gentle pressure. D: cover the exposed cord with a dry, sterile wrap.
place her in a knee-chest position. Explanation: Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a knee-chest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels.
While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? A: tachypnea and a widening pulse pressure B: tachycardia and a falling blood pressure C: bradycardia and auscultation of fluid in the base of the lungs D: bradypnea and hypertension
tachycardia and a falling blood pressure -Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.
A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next? A: Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis B: Move the client into a hands-and-knees position, to straighten the sacral curve and release the posterior shoulder C: Apply downward pressure above the pubic bone of the client, in an attempt to rotate the anterior shoulder D: Push the fetal head back into the uterus and prepare the client for cesarean birth
Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis Explanation: To implement McRoberts maneuver, the nurse brings the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis. This maneuver enlarges the space for delivery of the fetal shoulders. Applying pressure above the pubic bone is suprapubic pressure. Pushing the fetal head back into the vagina is a Zavanelli maneuver. Since the fetal head has been delivered, it is not safe to move the client to a hands-and-knees position.
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.
Use McRoberts maneuver. Explanation: 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 woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor? A: variable deceleration pattern B: fetal heart rate (FHR) increase to 200 beats/min C: early deceleration with each contraction D: late deceleration with late recovery following contraction
variable deceleration pattern Explanation: Umbilical cord prolapse can be seen after the membranes have ruptured, when the FHR is displaying a sudden variable deceleration FHR pattern on a fetal monitor. It is not uncommon for FHR to increase following a procedure. Early deceleration with each contraction is seen when the fetal head is being compressed through the pelvic opening. Late deceleration with late recovery following contraction is associated with uteroplacental insufficiency (UPI).
Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be most likely? A: 134 beats per minute B: 144 beats per minute C: 154 beats per minute D: 164 beats per minute
164 beats per minute -A fetal heart rate of 164 beats per minute (bpm) indicates fetal tachycardia. The normal range of FHR is between 120 and 160 bpm. When the FHR is above 160 bpm, it should be considered as fetal tachycardia.
During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. A: Assist with maneuvers. B: Keep time. C: Document events in the record. D: Lower the head of the bed. E:Administer oxytocin to increase the contractions.
-Assist with maneuvers. -Keep time. -Document events in the record. -Lower the head of the bed. Explanation: The nurse will assist with the maneuvers used to facilitate birth of the shoulders. The nurse also keeps time, by calling out how much time has passed, since the head was delivered. The fetus needs to be completely birthed within 5 minutes to minimize the risk of hypoxia. Documentation of the events taking place, including the use of maneuvers and maternal and fetal response, is another nursing responsibility. The head of the bed needs to be lowered to a flat position to increase the effectiveness of McRoberts maneuver and to give the health care provider the maximum space to birth the shoulders. Oxytocin is not administered in this situation. The shoulders are stuck, and making the contractions stronger will not resolve the problem but will increase fetal distress.
A woman in active labor suddenly sits up, clutches her chest, screams with pain, and then collapses back on the bed. The RN notes she is unconscious and a bluish-gray color. Which interventions are considered the priority for the nurse to implement? Select all that apply. A: Apply oxygen mask and start oxygen at 10 L/min. B: Begin CPR immediately. C: Place stethoscope on the abdomen to verify fetal heart rate. D: Start oxytocin at 4 mu/min and titrate upward every 5 minutes. E: Call lab and request 4 units of whole blood stat.
Apply oxygen mask and start oxygen at 10 L/min. Begin CPR immediately. Explanation: Amniotic fluid embolism occurs when amniotic fluid is forced into an open maternal uterine blood sinus after a membrane rupture or partial premature separation of the placenta. The clinical picture is dramatic. The immediate management is oxygen administration by face mask or cannula. Within minutes, she will need CPR; however, CPR may be ineffective because these procedures do not relieve the pulmonary constriction. Blood still cannot circulate to the lungs. Death may occur within minutes. Taking time to listen to FHR is not the priority. Oxytocin will not help with embolism. If the woman survives and develops DIC, fibrinogen is the blood product of choice.
The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do? A: Bolus the client with another dose of medication through the epidural. B: Place the client in a knee-chest position. C: Turn the client on her left side. D: Prepare the client for a cesarean birth.
Prepare the client for a cesarean birth. Explanation: The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous effective pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.
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: Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. B: With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. 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.
Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. -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.
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? A: Slow the oxytocin infusion to the initial rate. B: Continue to monitor contractions and fetal heart rate. C: Stop the infusion immediately. D: Notify the birth attendant.
Stop the infusion immediately. Explanation: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.
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
external cephalic version -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.