NUR 113 Exam II

In a woman who measures 13 centimeters from the symphysis pubis to the sacral promontory, what would you estimate the obstetric conjugate to measure?

11 cm. The obstetric conjugate measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be measured directly, measure the diagonal conjugate and subtract 1.5 to 2.0 centimeters from the measurement.

natural timing - how long does the average nullipara labor last?

18 hours

Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as:

50% effaced A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 1/2 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.

In planning care for a pregnant adolescent, which of the following would be most age appropriate?

Allow her to weigh herself at clinic visits. Part of learning a sense of identity (the adolescent developmental task) is learning self-care. Participation in prenatal care can strengthen this. Remaining in school helps prepare an adolescent to be able to support a newborn financially.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best action would be to...?

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

The nurse is assessing the woman who has a forceps-assisted birth for complications. Which of the following would be least likely to occur in the mother?

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.

Premonitory Signs of Labor

Cervical Changes (softening, possible dilation) Lightening Increased energy level (nesting) Bloody show Braxton Hicks contractions (Do not want before 37 wks) SROM (Advise pt to come to the hospital right away)

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which of the following?

Crowning. Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction, documenting this as which of the following?

Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which of the following patterns would you anticipate seeing on the monitor?

Fetal heart rate declining late with contractions and remaining depressed. Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction

Cephalic

Head presented first - good thing

Fontanels

Intersections of sutures

Fetal Skull

Largest and least compressible structure - has sutures which allow for overlapping and changes in shape (molding)

A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. You notify the physician and take what action?

Prepare to assist with external version or prep for a cesarean section delivery. Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be delivered via a cesarean delivery. Piper forceps are used in the delivery 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. Counter pressure 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 positioning

When assessing fetal heart rate patterns, which of the following would alert the nurse to a possible problem?

Prolonged decelerations are associated with prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

A 32-year-old woman presents to the labor-and-delivery suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA. Document the fetal position in the clinical record using abbreviations (Box 8-1). The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter or abbreviation indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position

Fetal attitude

Refers to the relationship of fetal body parts to one another Denotes whether presenting parts are in flexion or extension Most common - complete flexion (Chin on chest)

Lie

Refers to the relationship of the long axis (spine) of the fetus to the long axis of the mother. (Can be described as longitudinal, transverse, or oblique)

Fetal Lie

Relationship of the long axis (spine) of the fetus to the long axis of the mother Types: Longitudinal - fetus is lying verticially in the uterus; further classificed as cephalic or breech; nearly all fetuses are in longitudinal lie at onset of labor Transvere - fetus is lying horizontally in the uterus; occurs in less than 1% of cases Oblique - Rare. Fetal spine and maternal spine are at 45-degree angles

A woman with cardiac disease delivered a seven pound baby by C-Section. Which of the following interventions should be implemented during the immediate postpartum period?

Rest, stool softeners, and monitoring tolerance of activity. A woman who has a cardiac condition is at increased risk in the postpartum period. She needs frequent assessment and observation for tolerance. She would also be given education to avoid straining activities such as bowel movements and would be encouraged to have stool softeners and increase fluid and fiber. Restricting the patient's activity to bed rest could be detrimental to the patient, as could be ambulating to the bathroom only. There is no reason to limit the visits with the infant

The nurse would prepare a client for amnioinfusion when which of the following occurs?

Severe variable decelerations are due to cord compression 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, descend in the pelvis, non-reassuring 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.

The nurse is monitoring a patient in labor who has had a previous cesarean section and is trying a vaginal birth with epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The patient reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

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 good 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 delivery.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. The nurse documents this finding as which of the following?

The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis. p 426

The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor.

The nurse needs further information to assist in determining if the woman is in true or false labor. She will need to ask the patient questions to seek further assessment and triage information. Having her wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. She should continue fluid intake until it is determined whether or not she is in labor. She may be in false labor, and more information should be obtained before she is brought to the hospital

Fetal Position

The relationship of the presenting part of the fetus to a specific section of the mother's pelvis.

True vs. False labor

Timing - true labor is regular, becomes closer together while false labor is irregular and the timing is not closer together Strength - true labor becomes stronger with time and vaginal pressure is normally felt while false labor is typically weak and does not get stronger with time Discomfort - true labor starts in the back and radiates towards the abdomen, false labor is felt in the front of the abdomen Change in activity - true labor contractions will continue no matter what positional changes are made, false labor stops or slows down with walking/making a position change

When to come to the hospital - true labor?

When contractions are 5 mins apart, last 45-60 seconds, and strong enough that a conversation is not possible

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which of the following?

When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place(precipitous labor).

Fetal Presentation

Which part comes out 1st? Affects the duration and difficulty of labor and the method of delivery Types: Cephalic - head presents first - most common type Breech - butt or feet present first Shoulder - shoulder, iliac crest, hand, or elbow presents first

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which of the following conditions in this client?

With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labo

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which of the following conditions in this client?

With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

Complications of rubella

deafness

Complications of chicken pox

encephalitis (swelling of the brain)

S/S of Rubella

fine raised rash, low grade fever, flu like symptoms

During the active phase of labor, the nurse should evaluate the labor pattern how often?

q 30 minutes Active labor is a phase when the cervix dilates from 4 to 8 centimeters. The contractions are progressing and occur every 2-5 minutes and last 45-60 seconds. The nurse needs to evaluate the labor pattern every 30 minutes. Longer than 30 minutes may result in missing a transition, and less than 30 minutes may be a waste of time and may cause significant inconveniences to the mother

A client with a high thoracic spinal cord injury has just begun labor. She has an indwelling urinary catheter. Her blood pressure has skyrocketed to 300/160 mm Hg. Which of the following interventions should the nurse implement to address this complication?

• Elevate the client's head • Check the catheter for kinks • Anticipate the need for an antihypertensive agent In a woman who has a high spinal cord injury (cervical or high thoracic), observe for autonomic dysreflexia during pregnancy, labor, and the immediate postpartum period. Extreme symptoms such as severe hypertension (300/160 mm Hg), throbbing headache, flushing of the skin and profuse diaphoresis above the level of the spinal lesion, nausea, and bradycardia may occur. Immediate action is necessary to protect against cerebrovascular accident or intraocular damage. Elevate a woman's head to reduce cerebral pressure and locate the irritating stimulus (usually a distended bladder or bowel). If bladder distention is the cause, the woman needs bladder pressure relieved by catheterization if an indwelling catheter is not in place. If a catheter is in place, check to see why it is not draining, then encourage it to drain by unkinking or flushing to allow urine to flow freely again. Anticipate the need for an antihypertensive agent to alleviate the extreme hypertension, although as soon as the source of irritation is removed, symptoms typically fade quickly. The catheter should not be removed. Performing a blood glucose test and administering an iron supplement are not indicated in this case, as neither hyperglycemia nor anemia is evident.