Maternity Chapter 21
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? prostaglandin laminaria breast stimulation amniotomy
amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.
The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? a. Prepare to assist the care provider with an amniotomy. b. Prepare the client for a cesarean birth. c. Prepare for a precipitous vaginal birth. d. Administer an analgesic to the client.
b. Prepare the client for a cesarean birth If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.
A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion? a. amniocentesis b. ultrasound c. triple marker screening d. human chorionic gonadotropin (hCG) level
b. ultrasound A client experiencing an intrauterine fetal demise (IUFD) is likely to seek care when she notices that the fetus is not moving or when she experiences contractions, loss of fluid, or vaginal bleeding. History and physical examination frequently are of limited value in the diagnosis of fetal death, since many times the only history tends to be recent absence of fetal movement and no fetal heart beat heard. An inability to obtain fetal heart sounds on examination suggests fetal demise, but an ultrasound is necessary to confirm the absence of fetal cardiac activity. Once fetal demise is confirmed, induction of labor or expectant management is offered to the client. An amniocentesis, hCG level, or triple marker screening would not be used to confirm IUFD.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? continuing to monitor maternal and fetal status auscultating the fetal heart rate at the level of the umbilicus applying suprapubic pressure against the fetal back noting the space at the maternal umbilicus
continuing to monitor maternal and fetal status 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
The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply. epidurals multiple gestation maternal diabetes maternal exhaustion excessive analgesia high fetal station at complete cervical dilation shoulder dystocia
epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffective pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation (dilatation).
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: increased risk for cord entanglement. potential lacerations and bleeding. increased risk for uterine rupture. damage to the maternal tissues.
potential lacerations and bleeding. 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.
A multipara woman is fully dilated and effaced and has been pushing for over 2 hours. The student nurse observing asks the nurse, "What is causing this to last so long?" Which response by the nurse would be the most accurate? "The fetus probably turned to a breech position at the last minute." "The fetal head is in an abnormal position." "The woman's bladder is too full, so the fetus cannot descend." "The fetal head and shoulders are too large to get through the canal."
"The fetal head is in an abnormal position." A deceleration phase has become prolonged when it extends beyond 1 hour in a multipara. A prolonged deceleration phase most often results from abnormal fetal head position. Usually the size of the fetal head and shoulders have been measured via ultrasound and considered adequate to descend before labor. If the fetus turned to a breech position, a cesarean birth would have been scheduled. The woman's bladder can be emptied via catheter while she is in bed, so this should not be the problem.
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: 3,500 g to 4000 g 4,000 g to 4500 g 2500 to 3000 g 3,000 g to 3500 g
4,000 g to 4500 g 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.
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? A full bladder or rectum can impede fetal descent. If the woman has a full bladder, labor may be uncomfortable for her. If the woman's bladder is distended, it may rupture. A full rectum can cause diarrhea
A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.
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 diluted as a "piggyback" infusion. Administer oxytocin in a 20 cc bolus of saline. Administer oxytocin diluted in the main intravenous fluid. Administer oxytocin in two divided intramuscular sites.
Administer oxytocin diluted as a "piggyback" infusion. 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'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 amnioinfusion. Administer oxygen at 10 L/min by face mask.
Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.
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? Allow the couple to spend as much time as they want with their stillborn infant. Avoid any discussion of the situation with the couple. Assist the family in making arrangements for their stillborn infant. Give the parents a lock of the infant's hair.
Avoid any discussion of the situation with the couple. 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.
As part of a review class for perinatal nurses, the nurse is explaining the laboratory and diagnostic tests that can be conducted to evaluate a woman's risk for preterm labor. The nurse determines that additional teaching is needed when the group identifies which test as being used? A. salivary estriol levels B. transvaginal ultrasound C. fetal fibronectin testing D. blood chemistry levels
D. blood chemistry levels Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, amniotic fluid analysis, fetal fibronectin testing, cervical length evaluation by transvaginal ultrasound, salivary estriol, and home monitoring of uterine activity to recognize preterm contractions. Blood chemistry levels will inform the primary care provider as to the condition of the mother but would not be definitive in determining preterm labor risks.
After only 45 minutes of labor, the client feels the urge to push. She pushes once and the baby's head is visible. With the next push, the head emerges. What is the immediate risk when the head is delivered too fast? Pelvic floor relaxation Vaginal stretching Bladder incontinence Perineal tearing
Perineal tearing The immediate risk of a precipitous delivery is perineal tearing, because the tissue does not have time to stretch naturally. Vaginal stretching has occurred as the fetus descended to the perineum. Bladder incontinence and pelvic floor relaxation are potential long-term consequences of a precipitous birth, but they are not the immediate concern.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: administer oxygen by mask. increase her intravenous fluid infusion rate. put firm pressure on the fundus of her uterus. tell the woman to take short, catchy breaths.
administer oxygen by mask 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? fetal heart tones signs of shock infection uterine stabilization
fetal heart tones 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 instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: increased number of overall pregnancies. longer length of labor. increasing birth weight. poor quality of prenatal care.
increasing birth weight. 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 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 3 hours b. less than 5 hours c. less than 8 hours d. less than 4 hours
less than 3 hours Precipitous labor is completed in less than 3 hours.
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? "Green might be a yeast infection and we need to culture the discharge." "This is meconium-stained fluid from the baby." "You have an infection and need antibiotics." "Amniotic fluid is normally green."
"This is meconium-stained fluid from the baby." Green-tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called meconium-stained fluid. This is more typical in a postdate pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid
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? Increased risk for infection Decreased strength of uterine contractions Increased risk for placental abruption Decreased fetal oxygenation
Decreased fetal oxygenation 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.
The nurse provides education to a postterm pregnant client. information will the nurse include to assist in early identification of potential problems? "Monitor your bowel movements for constipation." "Continue to monitor fetal movements daily." "Be sure to measure 24-hour urine output daily." "Increase your fluid intake to prevent dehydration."
Prepare for an emergency cesarean birth. The client has a class 3 placental abruption (abruptio placentae). There are signs of fetal distress; maternal tachycardia and hypotension; low hematocrit and hemoglobin; and borderline platelet count. To save the baby and mother, the baby needs to be born immediately via 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? Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. Place the client in Trendelenburg position and gently attempt to reinsert the cord. 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 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? Console her with the fact that she has other children. Tell her that the hospital will keep the photos for her in case she changes her mind. Apologize and tell her that the photos will be destroyed immediately. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.
Tell her that the hospital will keep the photos for her in case she changes her mind. 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 in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? The parents continue to mourn the loss of their infant. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn. The parents are beginning to demonstrate positive grieving behaviors. The parents just cannot believe their perfect infant died.
The parents are beginning to demonstrate positive grieving behaviors. An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able to give birth to a healthy child. Some infants will die. Outcome achievement might include the client begins positive grieving behaviors (touching, counting toes/fingers, etc.) in response to the loss of the newborn. The other statements are probably accurate but are not written as outcome statements
A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? a. Apply a warm washcloth to the lower back. b. Place the client supine with the head of bed elevated 30 degrees. c. Have the health care provider administer a pudendal block. d. Use a fist to apply counterpressure to the lower back.
Use a fist to apply counterpressure to the lower back. Counterpressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.
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? administering oxytocin encouraging the woman to assume a hands-and-knees position providing a comfortable environment with dim lighting preparing the woman for an amniotomy
administering oxytocin 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.
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. Call the hospital chaplain to talk to the parents. c. Offer to take pictures and footprints of the infant once it is delivered. d. Recommend that she not hold the infant after it is delivered so as to not upset her more.
c. Offer to take pictures and footprints of the infant once it is delivered. 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.
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. brief. c. erratic. d. poor in quality.
c. 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, brief, and lack sufficient intensity to dilate and efface the cervix.
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? fetus descends 2 cm per hour fetus descends 1 cm per hour cervix dilates 2 cm per hour cervix dilates 1 cm per hour
cervix dilates 1 cm per hour A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation (dilatation). If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out
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? administration of oxytocin cesarean birth administration of morphine sulfate darkening room lights and decreasing noise and stimulation
cesarean birth 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 client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? elevated blood glucose depressed deep tendon reflexes bradycardia tachypnea
depressed deep tendon reflexes 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.
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? hospitalization, tocolytic, and corticosteroids bed rest and hydration at home careful monitoring of fetal kick counts an emergency cesarean birth
hospitalization, tocolytic, and corticosteroids 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 kick counts is typically done with a postterm pregnancy.
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? fraternal neither type results from a split ovum both types can result from the split ovum identical
identical 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 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? normal labor precipitate labor preterm labor dystocia
preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth.
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? encouraging the women to change positions frequently preparing the woman for an amniotomy providing a comfortable environment with dim lighting administering oxytocin
providing a comfortable environment with dim lighting 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? contractions most forceful in the middle of uterus rather than the fundus fetal buttocks as the presenting part reports of severe back pain lack of cervical dilation (dilatation) past 2 cm
reports of severe back pain 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.
