Nursing Management of Labor and Birth at Risk

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? -2 cm/hour for cervical dilation -1/2 cm/hour for cervical dilation -1 cm/hour for cervical dilation -1/4 cm/hour for cervical dilation

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

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? -hematocrit of 36% (0.36) -45 ml urine output in 2 hours -hemoglobin of 13 g/dl (130 g/L) -platelet count of 150,000 mm3

45 ml urine output in 2 hours 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.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? -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 bladder or rectum can impede fetal descent. -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.

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? -To lessen the mother's pain -The fetus is descending too slowly -Abnormal position of the fetal head -Reduce risk of complications

Abnormal position of the fetal head 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 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. 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.

Bishop Scoring System 1

Dilation: 1-2 Effacement: 40-50 % Station: -2 Cervical Consistency: Medium Position of Cervix: Mid-position

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? -Monitor heart rate for tachycardia. -Monitor fetal movements to ensure they are neurologically intact. -Look for late decelerations on monitor, which is associated with fetal anoxia. -Monitor fetal blood pressure for signs of shock (low BP, high FHR).

Look for late decelerations on monitor, which is associated with fetal anoxia. A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.

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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.

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

Sudden shortness of breath 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.

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 -preparing the woman for an amniotomy -encouraging the woman to assume a hands-and-knees position -providing a comfortable environment with dim lighting

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 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? -applying a heating pad to the back -applying ice to the back -applying counterpressure to the back -performing acupuncture on the back

applying counterpressure to the back 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.

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

caput succedaneum 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.

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? -well coordinated. -poor in quality. -brief. -erratic. TAKE ANOTHER QUIZ

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.

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? -less than 5 hours -less than 3 hours -less than 4 hours -less than 8 hours

less than 3 hours Precipitous labor is completed in less than 3 hours.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? -magnesium sulfate -nifedipine -indomethacin -betamethasone

magnesium sulfate 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.

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? -macrosomia -preterm labor -dystocia -normal labor

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. It is not normal labor. Macrosomia is a large fetus. Dystocia is difficult or abnormal labor.

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? -providing a comfortable environment with dim lighting -administering oxytocin -preparing the woman for an amniotomy -encouraging the women to change positions frequently

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).

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

the 41-year-old client who conceived by in vitro fertilization 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 fibroid tumors 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? -transverse lie -anterior fetal position -cephalic presentation -occipitoposterior position

transverse lie A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroid tumors 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 woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? -compression on the inferior vena cava -an amniotic embolism to the lungs -an undiagnosed abdominal aorta aneurysm -uterine rupture

uterine rupture If a uterus should rupture, the woman experiences a sudden, severe pain during a strong labor contraction, which she may report as a "tearing" sensation. Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency. Signs of hypotensive shock begin, including a rapid, weak pulse, falling blood pressure, cold and clammy skin, and dilation of the nostrils from air starvation. Fetal heart sounds fade and then are absent.

Administering Tocolytic Therapy

-Tocolysis is the use of drugs to inhibit uterine contractions. The primary goals of tocolytic therapy are to arrest labor and delay birth for up to 48 hours, to initiate prophylactic corticosteroid therapy when indicated for stimulation of fetal lung maturity, and to arrange for maternal-fetal transport to a perinatal tertiary care hospital. A firm diagnosis of preterm labor is necessary before treatment is considered. Diagnosis requires the presence of both uterine contractions and cervical change (or an initial cervical examination of more than 2 cm and/or more than 80% effacement in a nulliparous client). A cause for preterm labor should always be sought. -Primary prevention of preterm labor remains an elusive goal. Effective, evidence-based strategies for preventing preterm births include: smoking and substance use cessation; adequate nutrition and weight gain, pregnancy spacing intervals of 18 months; progesterone therapy for select women at risk; cervical cerclage for women with shortened cervixes; treating infections; and reducing perinatal stress

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 Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. -Assist with maneuvers. -Keep time. -Document events in the record. -Lower the head of the bed. -Administer oxytocin to increase the contractions.

Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed. 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.

Bishop Scoring System 2

Dilation: 3-4 Effacement: 60-70 % Station: -1 or 0 Cervical Consistency: soft Position of Cervix: Anterior

Medications Used with Preterm Labor Betamethasone (Celestone)

Indication: Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 weeks' gestation. Nursing Actions: -Administer two doses intramuscularly 24 hours apart. -Monitor for maternal infection or pulmonary edema. -Educate parents about potential benefits of drug to preterm infant. -Assess maternal lung sounds and monitor for signs of infection.

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? -cesarean birth -administration of oxytocin -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 nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply. -magnesium sulfate -atosiban -indomethacin -nifedipine -nitroglycerin

magnesium sulfate atosiban indomethacin nifedipine Medications commonly used for tocolysis include magnesium sulfate, atosiban, indomethacin, and nifedipine. These drugs are used "off label," meaning that they are effective but have not been officially tested and developed for this purpose by the US Food and Drug Administration (FDA).

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? -Low potassium or elevated glucose, tachycardia, chest pain -Respiratory depression, hypotension, absent tendon reflexes -Severe lower back pain, leg cramps, sweating -Pain in the abdomen, shoulder, or back

Respiratory depression, hypotension, absent tendon reflexes Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other options are incorrect indications of magnesium sulfate toxicity.

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

Severe variable decelerations occur and 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; 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 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? -Apologize and tell her that the photos will be destroyed immediately. -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. -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.

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? -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 full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

Bishop Scoring System 3

Dilation: 5-6 Effacement: 80% Station: +1 or +2 Cervical Consistency: Very Soft Position of Cervix: Anterior

Bishop Scoring System 0

Dilation: Closed Effacement: 0- 30% Station: -3 Cervical Consistency: Firm Position of Cervix: Posterior

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

"Continue to monitor fetal movements daily." The nurse will teach the postterm client to monitor fetal movements 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? -"Dystocia is diagnosed at the start of labor." -"Dystocia is not diagnosed until after the birth." -"Dystocia is diagnosed after labor has progressed for a time." -"Dystocia cannot be diagnosed until just before birth."

"Dystocia is diagnosed after labor has progressed for a time." 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.

A pregnant woman gives birth to a term fetus who has died in utero. She requests time after the birth to hold her baby. What is the best response by the nurse? -"You don't want to see your baby like this. I will take the baby away for you." -"This was nature's way of taking care of a defective baby." -"You can hold your baby for a few minutes, but then I must take it to the nursery to do the paperwork." -"Hold your baby as long as you like. Please let me know what I can do to help you."

"Hold your baby as long as you like. Please let me know what I can do to help you." A woman who has just received a diagnosis of fetal demise is experiencing a terrific loss. The nurse should be available to her without intruding and answer her questions honestly. He or she should encourage the woman to hold and name her baby, if she is able.

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 an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question? -"Maybe your uterus is just tired and needs a rest." -"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." -"Maybe your baby has developed hydrocephaly and the head is too swollen." -"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." Arrest of descent results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the second stage is CPD. Rest should allow the uterine contractions to be more efficient. The hormones secreted during pregnancy allow ligaments to soften so bones can shift to allow birth. Ultrasound would have previously been diagnosed prior to the onset of labor.

Administering Tocolytic Therapy cyclooxygenase inhibitor

(indomethacin [Indocin]) reduces prostaglandin synthesis from decidual macrophages. It readily crosses the placenta and can cause oligohydramnios due to a decrease in fetal renal blood flow if used for more than 48 hours. Maternal side effects include nausea, vomiting, and gastritis. During treatment, urine output, maternal temperature, and amniotic fluid index (AFI) should be evaluated periodically. The initial loading dose is 50 to 100 mg orally or rectally followed by 25 to 50 mg every 6 hours for eight doses. Indomethacin therapy is not recommended for gestations of 32 weeks or longer

Absolute contraindications to administering tocolytic agents to stop labor include

-Absolute contraindications to administering tocolytic agents to stop labor include intrauterine infection, active hemorrhage, fetal distress, fetus before viability, fetal abnormality incompatible with life, fetal growth restriction severe preeclampsia, heart disease, prolonged premature rupture of the membranes (PPROM), and intrauterine demise. Bed rest and hydration are commonly recommended but without proven efficacy.

Medications Used with Preterm Labor Magnesium sulfate

Indication: -Relaxes uterine muscles to stop irritability and contractions, to arrest uterine contractions for preterm labor (off-label use). -Has been used in seizure prophylaxis and treatment of seizures in preeclamptic and eclamptic clients for almost 100 years. Nursing Actions: -Administer IV with a loading dose of 4-6 g over 15-30 minutes initially, and then maintain infusion at 1-4 g/hr. -Assess vital signs and deep tendon reflexes (DTRs) hourly; report any hypotension or depressed or absent DTRs. -Monitor level of consciousness; report any headache, blurred vision, dizziness, or altered level of consciousness. -Perform continuous electronic fetal monitoring; report any decreased FHR variability, hypotonia, or respiratory depression. -Monitor intake and output hourly; report any decrease in output (<30 mL/hr). -Assess respiratory rate; report respiratory rate <12 breaths/min; auscultate lung sounds for evidence of pulmonary edema. -Monitor for common maternal side effects, including flushing, nausea and vomiting, dry mouth, lethargy, blurred vision, and headache. -Assess for nausea, vomiting, transient hypotension, and lethargy. -Assess for signs and symptoms of magnesium toxicity, such as decreased level of consciousness, depressed respirations and DTRs, slurred speech, weakness, and respiratory and/or cardiac arrest. -Have calcium gluconate readily available at the bedside to reverse magnesium toxicity.

Medications Used with Preterm Labor Nifedipine (Procardia)

Indication: Blocks calcium movement into muscle cells, inhibits uterine activity to arrest preterm labor. Nursing Actions: -Use caution if giving this drug with magnesium sulfate because of increased risk for hypotension. -Monitor blood pressure hourly if giving with magnesium sulfate; report a pulse rate >110 bpm. -Monitor for fetal effects such as decreased uteroplacental blood flow manifested by fetal bradycardia, which can lead to fetal hypoxia. -Monitor for adverse effects, such as flushing of the skin, headache, transient tachycardia, palpitations, postural hypertension, peripheral edema, and transient fetal tachycardia. -Contraindicated in women with cardiovascular disease or hemodynamic instability.

Medications Used with Preterm Labor Indomethacin (Indocin)

Indication: Inhibits prostaglandins, which stimulate contractions; inhibits uterine activity to arrest preterm labor. Nursing Actions: -Continuously assess vital signs, uterine activity, and FHR. -Administer oral form with food to reduce gastrointestinal irritation. -Do not give to women with peptic ulcer disease. Schedule ultrasound to assess amniotic fluid volume and function of ductus arteriosus before initiating therapy; monitor for signs of maternal hemorrhage. -Be alert for maternal adverse effects such as nausea and vomiting, heartburn, rash, prolonged bleeding time, oligohydramnios, and hypertension. -Monitor for neonatal adverse effects, including constriction of ductus arteriosus, premature ductus closure, necrotizing enterocolitis, oligohydramnios, and pulmonary hypertension. -Contraindicated in >32 weeks' gestations, fetal growth restriction, history of asthma, urticaria, or allergic-type reactions to aspirin or nonsteroidal antiinflammatory drugs.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? -Breech presentation -Fetal macrosomia -Occiput posterior position -Nongynecoid pelvis

Occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize? -Side-lying position -Pain relief measures -Immediate cesarean birth -Oxytocin administration

Pain relief measures 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.

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 just cannot believe their perfect infant died. -The parents are beginning to demonstrate positive grieving behaviors. -The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn.

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.

Administering Tocolytic Therapy Magnesium sulfate

This agent acts as a physiologic calcium antagonist and a general inhibitor of neurotransmission. Expect to administer it intravenously. Monitor the woman for nausea, vomiting, headache, weakness, hypotension, and cardiopulmonary arrest. Frequent monitoring of maternal respiratory effort and deep tendon reflexes is essential for early recognition of overdose. Because magnesium is exclusively excreted by the kidneys, adequate renal function is essential for safe administration. Assess the fetus for decreased FHR variability, drowsiness, and hypotonia. Magnesium has a wide margin of safety but is not more effective in delaying preterm birth as any other tocolytic agent. However, if administered prenatally, it is effective in helping women who develop preeclampsia and helps in fetal neuroprotection

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. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

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? -Use McRoberts maneuver. -Use Zavanelli maneuver. -Apply pressure to the fundus. -Attempt to push in one of the fetus's shoulders.

Use McRoberts maneuver. 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 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? -Place the client supine with the head of bed elevated 30 degrees. -Use a fist to apply counterpressure to the lower back. -Apply a warm washcloth to the lower back. -Have the health care provider administer a pudendal block.

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 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.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? -placental separation -aspiration -amniotic fluid embolism -congestive heart failure

amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

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 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.

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? -blood chemistry levels -fetal fibronectin testing -salivary estriol levels -transvaginal ultrasound

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.

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

brachial plexus assessment 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.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation? -face and brow presentation -breech presentation -persistent occiput posterior presentation -normal presentation

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left (LOT) or right occiput transverse (ROT) position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

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? -complications of a post-term pregnancy -complications of preterm labor -complications of placenta previa -placental abruption (abruptio placentae)

complications of a post-term pregnancy 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.

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

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 nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which condition should the nurse monitor the fetus? -fetal hypoxia -preeclampsia -coagulation defects -placental pathology

fetal hypoxia The nurse should monitor for fetal hypoxia in cases of umbilical cord prolapse. Because this is the fetus's only lifeline, fetal perfusion deteriorates rapidly. Complete occlusion renders the fetus helpless and oxygen deprived. Preeclampsia, coagulation defects, and placental pathology are not risks associated with umbilical cord prolapse.

A client has arrived to the birthing center in labor, requesting a VBAC. After reading the client's previous history, the nurse anticipates that the client would be a good candidate based on which finding? -had previous lower abdominal incision -had prior classic uterine incision -had prior transfundal uterine surgery -has a contracted pelvis

had previous lower abdominal incision The choice of a vaginal or repeat cesarean birth can be offered to women who have had a lower abdominal incision. Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse ("bikini cut") cesarean scar, contracted pelvis, and inadequate staff at the facility if an emergency cesarean birth is required.

A client in labor has been diagnosed with shoulder dystocia. Which risk factors would the nurse expect in the prenatal history? Select all that apply. -documented intrauterine growth restriction -maternal cervical insufficiency -history of maternal diabetes -dates indicating a post-term pregnancy -measurements indicating fetal macrosomia

history of maternal diabetes dates indicating a post-term pregnancy measurements indicating fetal macrosomia Shoulder dystocia is an obstetric emergency as the shoulders are stuck in the bony pelvis, preventing delivery. Risk factors of shoulder dystocia include maternal diabetes, maternal obesity, post-term pregnancy, fetal macrosomia, previous history of shoulder dystocia, and multiparity. Intrauterine growth restriction and cervical insufficiency are not the risks associated with shoulder dystocia. Intrauterine growth restriction is one of the factors that increases the risk of a breech presentation. Cervical insufficiency is a risk factor related to preterm labor.

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? -bed rest and hydration at home -hospitalization, tocolytic, and corticosteroids -an emergency cesarean birth -careful monitoring of fetal kick counts

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 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 condition in this client? -hypotonic contractions -hypertonic contractions -uncoordinated contractions -Braxton Hicks contractions

hypotonic contractions 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.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: -longer length of labor. -increased number of overall pregnancies. -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.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: -increased risk for uterine rupture. -potential lacerations and bleeding. -increased risk for cord entanglement. -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 pregnant client presents to the emergency department reporting back-to-back contractions. Within 2 hours, the client is completely effaced and 9 cm dilated, and the fetal head is showing. Within minutes the client gives birth with only the nurse in attendance. This is an example of which occurrence? -labor dystocia -precipitate labor -uterine dysfunction -protraction disorder

precipitate labor A precipitate labor can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. It is defined as labor that takes less than 3 hours from the start of contractions to birth. Labor dystocia refers to lack of progression and there are two types: protraction and arrest. Uterine dysfunction refers to types of uterine contractions and are labeled as either hypertonic or hypotonic.

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

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. REVIEW PAGE 771

Administering Tocolytic Therapy Calcium channel blockers

usually treat hypertension, angina, and arrhythmias but also promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. Although calcium channel blockers may be prescribed to manage preterm labor, available literature provides little evidence that they have better efficacy in treating preterm labor than any other tocolytic agent. Administer calcium channel blockers (nifedipine) orally or sublingually every 4 to 8 hours as ordered. Monitor the woman for hypotension, reflex tachycardia, headache, nausea, and facial flushing.

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? -uterine hypertonicity -active genital herpes infection -blood pressure of 130/88 mm Hg -decreased urine output

uterine hypertonicity 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.