Maternal-Newborn Ch. 21 Complications occurring before labor and delivery
A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse? "Go to the hospital now because this could be very dangerous for the baby." "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." "You may have just passed some urine. If it were amniotic fluid, there would be much more than that." "It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."
"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placentae and placenta previa. Which statement should the nurse include in the teaching? "Placenta previa causes painful, dark red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruption placenta is associated with bright red painless bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." "Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." "Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the fundus; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." "Placenta previa causes painful, dark red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the fundus; abruptio placentae is associated with right red painless bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."
"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."
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? 11 8 6 3
11
The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider? hematocrit of 36% 45 ml urine output in 2 hours hemoglobin of 13 g/dl platelet count of 150,000 mm3
45 ml urine output in 2 hours
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: 5. 6. 7. 9.
5
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? Administer oxytocin in a 20 cc bolus of saline. Administer oxytocin in two divided intramuscular sites. Administer oxytocin diluted in the main intravenous fluid. Administer oxytocin diluted as a "piggyback" infusion.
Administer oxytocin diluted as a "piggyback" infusion.
A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide? "Amniotic fluid is normally green." "This is meconium-stained fluid from the baby." "You have an infection and need antibiotics." "Green might be a yeast infection and we need to culture the discharge."
This is meconium-stained fluid from the baby."
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? breast stimulation amniotomy laminaria prostaglandin
amniotomy
A nurse is conducting an assessment of a woman who has experienced PROM. Which finding would lead the nurse to suspect infection as the cause of a client's PROM? yellow-green fluid blue color on Nitrazine testing ferning foul odor
foul odor
A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which factor would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? aging of the placenta increased amniotic fluid volume meconium aspiration cord compression
increased amniotic fluid volume
A nurse is explaining to a group of nurses new to the labor and birth unit about about methods used for cervical ripening. The group demonstrates understanding of the information when they identify which method as a mechanical one? herbal agents laminaria membrane stripping amniotomy
laminaria (balloon catheter,hygroscopic dilators)
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? dysfunctional labor pattern postterm status prolonged ruptured membranes overdistended uterus
overdistended uterus
A patient who is at 7 months' gestation presents to the emergency department with reports of a large gush and continuous leaking of fluid from her vagina. She does have some slight pelvic pressure but denies any contractions. This patient is showing clinical signs of which of the following? precipitous labor premature rupture of membranes dystocia all of the above
premature rupture of membranes
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? posterior position firm closed shortened
shortened
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? bronchodilators tocolytic therapy muscle relaxants anti-anxiety therapy
tocolytic therapy
A pregnant woman at the emergency department informs staff that she is at least 2 weeks past her due date. The physician begins to perform several tests to determine fetal age. The nurse anticipates that the woman's amniotic fluid volume will be decreased. How would the nurse measure the amniotic fluid in this situation? x-ray ultrasound aspiration palpation
ultrasound
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? uterine hyperstimulation headache blurred vision hypotension
uterine hyperstimulation
A pregnant patient at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse? "Go to the hospital now, because this could be very dangerous for the baby." "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." "You may have just passed some urine. If it were amniotic fluid, there would be much more than that." "It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."
"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."
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? Turn down oxytocin administration by half. Start administering tocolytic therapy. Assess contractions by using external monitor. Administer hydration and sedation frequently.
Assess contractions by using external monitor.
A pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient? Assess fetal heart sounds with an external monitor. Help the patient remain ambulatory to reduce bleeding. Assess uterine contractions by an internal pressure gauge. Prepare for a vaginal examination to assess the extent of bleeding.
Assess fetal heart sounds with an external monitor.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? Assess fetal heart sounds. Place the woman in Trendelenburg position. Administer oxygen at 10 L/min by face mask. Administer amnioinfusion.
Assess fetal heart sounds.
During a prenatal ultrasound, the client is discovered to have a placenta succenturiata. Following delivery of the fetus and placenta, which nursing assessment is most important? Assessment for hemorrhage Assessment for pain Assessment for a thrombus Assessment for shortness of breath
Assessment for hemorrhage
When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications? Increase fluid intake to prevent dehydration. Be sure to measure 24-hour urine output daily. Be sure to monitor fetal movements daily. Monitor bowel movements.
Be sure to monitor fetal movements daily.
When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications? Increase fluid intake to prevent dehydration. Be sure to measure 24-hour urine output daily. Be sure to monitor fetal movements daily. Monitor bowel movements.
Be sure to monitor fetal movements daily.
The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions? Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min. After one hour, titrate the infusion upward by 1 to 2 mu/min until contractions are adequate. Start oxytocin drip, piggyback to main IV line to port closest to client. Discontinue infusion if contractions are every 2 minutes lasting 60 to 90 seconds each.
Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min.
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? Make sure the epidural medication is turned down. Check for a full bladder. Make sure the client is lying on her left side. Assess vital signs every 30 minutes.
Check for a full bladder.
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? Depressed deep tendon reflexes Tachypnea Bradycardia Elevated blood glucose
Depressed deep tendon reflexes
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? Depressed deep tendon reflexes Tachypnea Bradycardia Elevated blood glucose
Depressed deep tendon reflexes
A pregnant patient is prescribed to have labor induced with oxytocin. How should the nurse prepare to administer this medication? In a 20-cc bolus of saline In two divided intramuscular sites Diluted as a "piggyback" infusion Diluted in the main intravenous fluid
Diluted as a "piggyback" infusion
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? Fetal heart tones Signs of shock Infection Uterine stabilization
Fetal heart tones
A pregnant client in her 35th week of gestation arrives at the clinic with bright red vaginal spotting. An ultrasound indicates that the placenta is partially covering the cervical os. The nurse interprets this as which? Grade I- Low lying placenta Grade II- Marginal previa Grade III- Partial previa Grade IV- Complete previa
Grade III- Partial previa
A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? Exercise helps reduce the frequency of them. If rhythmical, they could indicate preterm labor. Lying down for a few hours will help them stop. They are false labor and do not need to be reported.
If rhythmical, they could indicate preterm labor.
A full-term pregnant client is being assessed for induction of labor. Her Bishop score is less than 6. Which prescription would the nurse anticipate? Insert a Foley catheter into the endocervical canal. Prepare the client for a cesarean birth. Administer oxytocin intravenously at 10 mU/minute. Rupture membranes.
Insert a Foley catheter into the endocervical canal
A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor? Reticulocyte count Lecithin/sphingomyelin ratio Nitrazine test Test for antiphospholipids
Lecithin/sphingomyelin ratio
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? Premature separation of the placenta Preterm labor that was undiagnosed Placenta previa obstructing the cervix Possible fetal death or injury
Premature separation of the placenta
A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client? Risk for fetal infection related to early rupture of membranes Hopelessness related to potential loss of pregnancy Anticipatory grieving related to high probability for fetal death from placental dysfunction Powerlessness related to inability to sustain pregnancy
Risk for fetal infection related to early rupture of membranes
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? Increase the oxytocin. Turn off the oxytocin. Increase the methotrexate. Turn off the methotrexate.
Turn off the oxytocin.
A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient? Amniotic fluid infection Amniotic fluid embolus Umbilical cord prolapse Placental abruption
Umbilical cord prolapse
A nurse is administering oxytocin to a woman in labor. The nurse monitors the infusion closely and notifies the health care provider if which condition occurs? Water intoxication Hypertension Uterine hypotonicity Fetal distress
Water intoxication
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? breast stimulation amniotomy laminaria prostaglandin
amniotomy
A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of abruptio placentae during birth. Which finding would help to support the nurse's suspicion? severe uterine pain board-like abdomen appearance of petechiae inversion of the uterus
appearance of petechiae
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: assess the rate of flow of the oxytocin infusion. administer oral orange juice for added potassium. assess her vaginally for full dilation. instruct her to breathe in and out rapidly.
assess the rate of flow of the oxytocin infusion.
The nurse would be alert for possible placental abruption during labor when assessment reveals which finding? macrosomia gestational hypertension gestational diabetes low parity
gestational hypertension
A client has been admitted with abruptio placentae. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? grade 2 grade 1 grade 3 grade 4
grade 2
A nurse is reviewing the medical record of a pregnant client diagnosed with placenta previa. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which type of placenta previa? total partial marginal low-lying
low-lying
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? hemorrhage macrosomia infection dystocia
macrosomia
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? betamethasone magnesium sulfate indomethacin nifedipine
magnesium sulfate
A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. nifedipine magnesium sulfate dinoprostone misoprostol indomethacin
nifedipine magnesium sulfate indomethacin
During their experience in L & D, a group of nursing students are observing a woman who is having uncoordinated contractions where the monitor shows some contractions close together, followed by a long period without any contractions. The nurse asks the students, "Which medication may help to stimulate a more effective, consistent pattern of contractions?" Which medication would be considered the best answer? morphine sulfate betamethasone terbutaline oxytocin
oxytocin
A patient who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the patient that pelvic rest involves which of the following? staying in bed at all times placing nothing in the vagina staying in bed with bathroom privileges staying off of the feet the majority of the day
placing nothing in the vagina
A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? preterm labor normal labor dystocia precipitate labor
preterm labor
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? posterior position firm closed shortened
shortened
A nurse is reviewing an article about preterm premature rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply. high body mass index urinary tract infection low socioeconomic status single gestations smoking
urinary tract infection low socioeconomic status smoking
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention? fetal heart rate of 150 beats/minute contractions every 2 minutes, lasting 45 seconds uterine resting tone of 14 mm Hg urine output of 20 mL/hour
urine output of 20 mL/hour
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? uterine hyperstimulation headache blurred vision hypotension
uterine hyperstimulation
