OB: AQ Labor Complications
A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for? A) Uterine inertia B) Prolapsed cord C) Imminent birth D) Precipitate labor
B) Prolapsed cord The feet or buttocks do not block the cervical opening effectively. The cord may slip through the cervix and become compressed. This is a life-threatening event for the fetus. Uterine inertia may result from fatigue or cephalopelvic disproportion; it is not related to fetal position. When a fetus is in the breech presentation the labor is usually long and difficult. Rapid dilation and precipitate labor may occur with fetuses in the cephalic position as well as the breech position.
Which medication should be administered to prevent symptoms of withdrawal in a laboring client who routinely uses heroin? A) Butorphanol B) Pentazocine C) Nalbuphine D) Dolophine
D) Dolophine Methadone is a narcotic analgesic used to prevent withdrawal symptoms in pregnant women who have stopped using heroin or other opioid drugs. Butorphanol, pentazocine, and nalbuphine are all narcotic agonist-antagonists and may cause acute withdrawal symptoms in the woman and fetus.
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? A) Call the client's mother and request a verbal consent. B) Proceed with the preparation and forgo written consent. C) Have the surgeon and attending primary healthcare provider sign the consent form. D) Sign the consent form and have the nurse manager countersign the form.
C) Have the surgeon and attending primary healthcare provider sign the consent form. The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.
A woman at 39 weeks' gestation whose membranes have ruptured at home arrives at the clinic to be evaluated. Assessment reveals mild irregular contractions 10 to 15 minutes apart, and a fetal heart rate (FHR) of 186 beats/min is auscultated between contractions. In light of this assessment, what does the nurse conclude? A) The fetus is not at risk. B) A precipitous birth is imminent. C) This is a response to an infection. D) A further assessment is necessary.
D) A further assessment is necessary. The fetal heart rate should be 110 to 160 beats/min; an FHR of 186 is tachycardic, and further evaluation is necessary because the fetus may be at risk. The data indicate that the client is in early labor. Although fetal tachycardia is associated with infection, there are other causes. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.
A client who is having a difficult labor is found to have cephalopelvic disproportion. Which prescription should the nurse question? A) Maintain nothing by mouth (NPO) status. B) Start a peripheral intravenous (IV) drip of 25% normal saline. C) Record fetal heart tones every 15 minutes. D) Piggyback another 10-unit bag of oxytocin.
D) Piggyback another 10-unit bag of oxytocin. When there is cephalopelvic disproportion, a cesarean birth is indicated; infusing oxytocin at this time could result in fetal compromise and uterine rupture. The NPO status is appropriate in anticipation of a cesarean birth. A peripheral IV is needed not only for hydration but also for venous access if IV medications become necessary. The client probably has an electronic monitor recording the fetal heart rate and uterine contractions; the findings of these assessments should be documented regularly in accordance with hospital protocol.
When entering the room of a client in active labor to answer the call light, the nurse sees that she is ashen gray, dyspneic, and clutching her chest. What should the nurse do immediately after pressing the emergency light in the client's room? A) Administer oxygen by facemask B) Check for rupture of the membranes C) Begin cardiopulmonary resuscitation (CPR) D) Increase the rate of intravenous (IV) fluids
A) Administer oxygen by facemask The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential. The client is experiencing an emergency situation; checking for rupture of membranes is irrelevant at this time. The client is breathing and conscious; CPR is not indicated, but it may become necessary if her condition worsens. It is not necessary to increase the IV fluid rate, although the current rate should be maintained.
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? A) Assessing maternal vital signs B) Planning for an emergency birth C) Administering oxygen by way of nasal cannula D) Preparing for fetal scalp blood sampling
A) Assessing maternal vital signs A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high flow oxygen via nonrebreather if assessment of the external monitoring is not reassuring, but this is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.
After a client's membranes rupture spontaneously, the nurse visualizes the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority. A) Call for assistance and don sterile gloves. B) Administer oxygen to the mother and monitor fetal heart tones. C) Put a rolled towel under one hip and place the patient in the modified Sims position. D) Insert two fingers into the vagina and exert upward pressure against the fetal presenting part.
A) Call for assistance and don sterile gloves. D) Insert two fingers into the vagina and exert upward pressure against the fetal presenting part. C) Put a rolled towel under one hip and place the patient in the modified Sims position. B) Administer oxygen to the mother and monitor fetal heart tones. This is an emergency, and additional personnel should be sought immediately. Sterile gloves should be donned before fingers are placed in the client's vagina. Exerting pressure against the presenting part relieves compression of the umbilical cord. The rolled towel and modified Sims position augment the relief of pressure against the cord. Oxygen administration increases the amount of oxygen perfusing the placenta. Fetal response to the event should be assessed with continuous monitoring of the fetal heart tone.
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. Which observation requires the nurse to notify the primary healthcare provider? A) Greenish amniotic fluid B) Shortened intervals between contractions C) Clear amniotic fluid with specks of mucus D) Maternal temperature of 99.1° F (37.3° C)
A) Greenish amniotic fluid Greenish amniotic fluid indicates the presence of meconium and should be reported to the primary healthcare provider. The interval between contractions should shorten as labor progresses. Clear fluid with specks of mucus is the description of normal amniotic fluid. There may be a slight increase in temperature related to the stress of labor, and it should be monitored. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.
The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. What does the nurse recognize this to indicate? A) A potential for cord prolapse B) Evidence of fetal heart abnormalities C) A common occurrence in breech presentations D) A condition requiring immediate notification of the primary healthcare provider
C) A common occurrence in breech presentations Sudden rupture of membranes followed by the appearance of meconium occurs in breech presentation when pressure on the fetal abdomen from the contractions forces meconium from the bowel. Cord prolapse is not an absolute; however, it may occur if the presenting part does not fill the pelvic cavity. Fetal heart abnormalities are identified by means of auscultation or continuous electronic fetal monitoring, not by the presence of meconium. Immediate notification of the primary healthcare provider is unnecessary.
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? A) Placenta previa B) Precipitous birth C) Abruptio placentae D) Breech presentation
C) Abruptio placentae Abruptio placentae indicates a premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to a conclusion regarding precipitous birth. Fetal presentation is not related to the client's signs and symptoms.
A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks' gestation. Which condition is a contraindication to the use of oxytocin induction? A) Chorioamnionitis B) Postterm pregnancy C) Active genital herpes infection D) Hypertension associated with pregnancy
C) Active genital herpes infection Oxytocin is not administered when a woman has an active genital herpes infection. In this case, the baby would be delivered by means of cesarean section to prevent it from being infected during birth. Chorioamnionitis, hypertension associated with pregnancy, and postterm pregnancy are all indications for the use of oxytocin induction.
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? A) Face B) Brow C) Breech D) Shoulder
C) Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.
The nurse is caring for a client during active labor. The recording on the electronic fetal monitor indicates fetal tachycardia. What should the nurse consider as a potential cause of this pattern? A) Fetal head compression B) Umbilical cord compression C) Increased maternal metabolism D) Pudendal anesthesia administration
C) Increased maternal metabolism A rapid fetal heart rate occurs when the maternal metabolism is accelerated; this can be a result of maternal fever. Fetal head compression causes early decelerations of the fetal heart rate, not fetal tachycardia. Umbilical cord compression is most commonly associated with variable decelerations. Pudendal anesthesia does not affect the fetal heart rate. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.
A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect? A) Heroin abuse B) Marijuana use C) Cocaine abuse D) Alcohol withdrawa
C) Cocaine abuse These signs are seen in pregnant women who abuse cocaine. Yawning, diaphoresis, rhinorrhea, restlessness, and excessive tearing are seen in heroin abuse. Chronic redness in the eyes, drowsiness, forgetfulness, and an unusual odor on the clothing or breath are signs of marijuana use. Anxiety, nervousness, shakiness, and slow speech are seen with alcohol withdrawal. The possibility of seizure activity must also be considered. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.
A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta? A) Put pressure on the fundus B) Ask the mother to bear down C) Have the mother breast-feed the newborn D) Place gentle continuous tension on the cord
C) Have the mother breast-feed the newborn Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions. Fundal pressure should not be used; it could cause uterine prolapse. Having the mother bear down could cause uterine prolapse. If the placenta is still attached to the uterine wall, placing gentle continuous tension on the cord could cause the cord to detach from the placenta or cause uterine prolapse.
A nurse is caring for a client with class III heart disease who is beginning the second stage of labor. For which medical intervention does the nurse prepare the client at this time? A) Elective cesarean birth to conserve energy B) Pudendal anesthesia to prevent restlessness C) Instrument extraction to ease a vaginal birth D) Intravenous tocolytic medication to weaken contractions
C) Instrument extraction to ease a vaginal birth Either the use of outlet forceps or vacuum extraction for the second stage of labor helps decrease the workload of the heart during expulsion, thereby facilitating the vaginal birth. Clients with cardiac problems can give birth vaginally when precautionary measures are instituted; it is preferable to prevent the secondary stress that surgery may impose. Epidural anesthesia is preferred, because there is no pain and energy is conserved. Tocolytic agents are used to halt preterm labor. The goal is to progress with labor as quickly as possible.
A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse alerts another nurse, who calls the primary healthcare provider. Place the following nursing interventions in the order in which they should be performed. A) Checking the fetal heart rate B) Administering oxygen by facemask C) Moving the presenting part off the cord D) Placing the client in the Trendelenburg position
C) Moving the presenting part off the cord D) Placing the client in the Trendelenburg position B) Administering oxygen by facemask A) Checking the fetal heart rate
A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client? A) Vaginal bleeding B) Urinary tract infection C) Prolapse of the umbilical cord D) Meconium in the amniotic fluid
C) Prolapse of the umbilical cord A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? A) Head compression B) Maternal hypothyroidism C) Uteroplacental insufficiency D) Umbilical cord compression
C) Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.
While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time? A) Monitoring the fetal heart rate B) Covering the cord with a saline dressing C) Pushing the cord back into the vaginal vault D) Holding the presenting part away from the cord
D) Holding the presenting part away from the cord Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? A) Cerebral hemorrhage B) Pulmonary edema C) Impending seizures D) Hypovolemic shock
D) Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? A) The fetus has a neural tube defect B) Fetal well-being is compromised C) Intrauterine infection has developed D) Meconium is being expelled with contractions
D) Meconium is being expelled with contractions In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluid is not a sign of a neural tube defect, regardless of presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate signs of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20% effaced and 2 cm dilated. Her membranes are intact and contractions are 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be? A) Educating the client on what to expect during labor B) Discussing pain management options available during labor C) Discussing the possibility of using oxytocin to move labor along E) Contacting the primary healthcare provider regarding the need for a cesarean birth
E) Contacting the primary healthcare provider regarding the need for a cesarean birth Transmission of genital herpes simplex virus (HSV-2) to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the primary healthcare provider of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth as soon as possible.
An amniotomy is performed to stimulate labor in a client at 42 weeks' gestation. Place the nursing care actions in their order of priority. A) Inspecting the perineum for umbilical cord prolapse B) Assessing the characteristics of the amniotic fluid C) Evaluating the client for signs of an infection D) Checking the fetal heart rate tracings
A) Inspecting the perineum for umbilical cord prolapse D) Checking the fetal heart rate tracings B) Assessing the characteristics of the amniotic fluid C) Evaluating the client for signs of an infection As fluid gushes from the amniotic sac, it may carry the umbilical cord out of the birth canal before the presenting part. The nurse should check for this occurrence first because it is an emergency and, if it occurs, immediate intervention will be necessary to prevent fetal harm. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.
A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. What is the priority medical intervention? A) Teaching coughing and deep-breathing techniques B) Sterilizing the surgical site and administering an enema C) Providing a sterile gown and inserting an indwelling catheter D) Obtaining informed consent and assessing the client for drug allergies
D) Obtaining informed consent and assessing the client for drug allergies In an emergency surgical situation when invasive techniques are necessary, it is important to have a signed consent on file as well as a history of the client's known allergies. Teaching coughing and deep-breathing techniques is not a priority in an emergency such as this. In an emergency, sterilization of the surgical site is performed in the operating room; an enema usually is not given before a cesarean, especially to a client who is bleeding, because it may stimulate contractions and worsen the hemorrhage.
A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth? A) Multipara with a shoulder presentation B) Multipara with a documented station of "floating" C) Primigravida with a fetus presenting in the occiput posterior position D) Primigravida with a twin gestation with the lowermost twin in the vertex presentation
A) Multipara with a shoulder presentation A shoulder presentation in a multipara is indicative of a transverse lie, and this necessitates a cesarean birth. It is not uncommon for the fetus of a multipara to be high at the beginning of labor; early engagement occurs more often with a primigravida. With an occiput posterior position the labor may be longer, but usually the mother can give birth vaginally. If the first twin is in the vertex presentation, a vaginal birth will be attempted with a double setup; if possible, the birth of the second twin also will be attempted vaginally.
A client who is having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the last two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. What type of pattern is this? A) Bradycardia B) Late decelerations C) Early decelerations D) Variable decelerations
B) Late decelerations Late decelerations begin during the peak of a contraction and continue after the contraction has ended. Bradycardia is a fetal heart rate slower than 110 beats/min for 10 minutes. Early decelerations mirror the contraction, beginning at the start of the contraction and ending when the contraction is over. Variable decelerations fall and rise abruptly and do not have the uniform appearance noted with early and late decelerations.
A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. Which position does the nurse encourage the client to assume? A) Supine B) Semi-Fowler C) Trendelenburg D) Left lateral recumben
B) Semi-Fowler The head of the bed should be elevated 45 degrees; this permits maximal chest expansion for ventilation. The laboring woman should not assume the supine position, because this would increase the risk of hypotension as a result of decreased venous return. The Trendelenburg position interferes with optimal cardiac function during labor and is contraindicated. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.
A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What instruction should the nurse provide to the client in this situation? A) Pant while pushing gently B) Breathe with her mouth closed C) Hold her breath while bearing down D) Pant while resisting the urge to bear down
D) Pant while resisting the urge to bear down Panting prevents the mother from putting pressure on the fetal head by pushing. The nurse applies gentle pressure against the fetus's head as it emerges to prevent a precipitous birth, which could result in central nervous system injury to the fetus and vaginal lacerations in the mother. It is impossible to pant and push at the same time. Breathing with the mouth closed promotes the bearing-down reflex. Bearing down during the birth is unsafe because both fetus and mother could be injured.
