OB Chapter 21 - Nursing Management of Labor and Birth at Risk

Contractions should occur every

2 to 3 minutes, lasting 40 to 60 seconds.

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

A) 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.

When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A) One who has undergone a previous myomectomy B) One who had a previous cesarean birth via a low transverse incision C) One who has a history of a contracted pelvis D) One who has avertical incision from a previous cesarean birth

B. VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.

VBAC

vaginal birth after cesarean section

A nurse is caring for a client who is scheduled to undergo amnioinfusion. The nurse knows that the client will not be able to have this procedure if which condition is present? a. uterine hypertonicity b. active genital herpes c. BP 130/88 d. decrease urine output

uterine hypertonicity

Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A) Posterior position B) Firm C) Closed D) Shortened

Shortened A ripe cervix is shortened, centered (anterior), softened, and partially dilated.

A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which of the following would the nurse most likely include as the most common problem? A) Macrosomia B) Breech presentation C) Persistent occiput posterior position D) Multifetal pregnancy

A,B,C

Tocolytic

Drug that inhibits uterine contractions.

Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are: A) Well coordinated B) Poor in quality C) Rapidly occurring D) Erratic

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.

These drugs promote uterine relaxation by interfering with uterine contraction

Tocolytic

fetopelvic disproportion

also called cephalopelvic; the head of the fetus is larger than the pelvic outlet

cervical ripeness

an assessment of the readiness of the cervix to afface and dilate in response to uterine contractions

amniotomy

artificial rupture of membranes

Client experiencing shoulder dystocia during birth. The nurse would place PRIORITY on performing which assessment postbirth? a. extensive lacerations b. monitor of cardiac anomaly c. brachial plexus assessment

brachial plexus to identify nerve damage

a client is admitted to the health facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? A. place client in lithonomy position for birth B. administer oxytocin 4 mU/min C. artificial rupture of membranes D. prepare client to have a cesarean birth

cephalopelvic disproportion is associated with postterm pregnancy. Client wouldn't be able to deliver vaginally

fetal demise

death of the fetus

Bishop score less than 6

indicates that cervical ripening method should be used before inducing labor

nitrazine paper

to confirm ruptured membrane

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman states that if she experiences any symptoms, she will do which of the following? A) "I'll sit down to rest for 30 minutes." B) "I'll try to move my bowels." C) "I'll lie down with my legs raised." D) "I'll drink several glasses of water."

"I'll drink several glasses of water." If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction.

A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which of the following would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? A) Aging of the placenta B) Increased amniotic fluid volume C) Meconium aspiration D) Cord compression

Increased amniotic fluid volume

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which of the following findings would require immediate intervention? a) Fetal heart rate of 150 beats/minute B) Contractions every 2 minutes, lasting 45 seconds C) Uterine resting tone of 14 mm Hg D) Urine output of 20 mL/hour

Urine output of 20 mL/hour Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. - Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. - A uterine resting tone greater than 20 mm Hg would require intervention.

A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which of the following? A) Uterine hyperstimulation B) Headache C) Blurred vision D) Hypotension

Uterine hyperstimulation A major adverse effect of the obstetric use of Cytotec is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Headache, blurred vision, and hypotension are associated with magnesium sulfate.

A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect? A) Amniotic fluid embolism B) Shoulder dystocia C) Uterine rupture D) Umbilical cord prolaps

Uterine rupture Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part.

Trendelenburg position

lying on back with body tilted so that the head is lower than the feet

a nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. Physician suspect client has amniotic fluid embolism. What other signs would alert the nurse?

nurse should watch for cyanosis, pulmonary edema, hypotension, seizures, tachycardia, coagulation failure, hemorrhage

Oxytocin is secreted by

posterior pituitary

A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure? A) "You'll need to stay in bed while you're having this procedure." B) "We'll give you an analgesic to help reduce the pain." C) "After the infusion, you'll be scheduled for a cesarean birth." D) "A suction cup is placed on your baby's head to help bring it out."

"You'll need to stay in bed while you're having this procedure." An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.

Symptoms of preterm labor

-increase vaginal discharge - pushing down sensation - low dull pain - menstrual- like cramps - uterine contraction without pain

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? A) 11 B) 8 C) 6 D) 3

11 The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11 would have the greatest chance for success.

A uterine resting tone greater than ____ mm Hg would require intervention.

20

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia? A) diabetes B) pendulous abdomen C) nullipara D) preterm birth

A) diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies.

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. Which findings would the nurse most likely assess? (Select all that apply.) A) Significant difficulty breathing B) Hypertension C) Tachycardia D) Pulmonary edema E) Bleeding with bruising

A,C,D,E The clinical appearance is varied, but most women report difficulty breathing. Other symptoms include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention? A) a forceps and vacuum-assisted birth B) a cesarean birth C) a precipitous birth D) artificial rupture of membranes

A. - a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. * The client may require a cesarean birth if the fetus cannot be delivered with assistance.

A group of nursing students are reviewing information about cesarean birth. The students demonstrate understanding of the information when they identify which of the following as an appropriate indication? (Select all that apply) A) Active genital herpes infection B) Placenta previa C) Previous cesarean birth D) Prolonged labor E) Fetal distress

Active genital herpes infection Placenta previa Previous cesarean birth Fetal distress

The nursing student demonstrates an understanding of dystocia with which statement? A) "Dystocia is not diagnosed until after birth." B) "Dystocia is diagnosed after labor has progressed for a time." C) "Dystocia is diagnosed at the start of labor." D) "Dystocia cannot be diagnosed until just before birth."

B) "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 woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45 mL/hour D) Alert level of consciousness

B. Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) "Holding a pillow against my incision will help me when I cough." B) "I'm going to have to wait a few days before I can start breast-feeding." C) "I guess the nurses will be getting me up and out of bed rather quickly." D) "I'll probably have a tube in my bladder for about 24 hours or so."

B. Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort.

The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? A. Hepatitis B. Herpes simplex virus C. Toxoplasmosis D. Human papillomavirus

B. -Herpes exposure during the birth process poses a high risk for mortality to the neonate. If the woman has active herpetic lesions in the genital tract, a surgical birth is planned to avoid this exposure. - Hepatitis is a chronic liver disorder, and the fetus if exposed would at most become a carrier; a surgical birth would not be expected for this woman. -Toxoplasmosis is passed through the placenta to the fetus prior to birth, so a cesarean birth would not prevent exposure. -HPV would be manifested clinically by genital warts on the woman, and a surgical birth would not be anticipated to prevent exposure unless the warts caused an obstruction.

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

BACK PAIN

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

C) 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, descend 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 client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth? A) monitor for a cardiac anomaly B) assess for cleft palate C) brachial plexus assessment D) extensive lacerations

C) 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.

A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn? A) Asphyxia B) Clavicular fracture C) Caput succedaneum D) Central nervous system injury

Caput succedaneum Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum.

A client who is in labor presents with shoulder dystocia of the fetus. Which is an important nursing intervention? A) Assess for prolonged second stage of labor with arrest of descent. B) Assess for reports of intense back pain in first stage of labor. C) Anticipate possible use of forceps to rotate to anterior position at birth. D) Assist with positioning the woman in squatting position.

D) Assist with position the woman in squatting position. The nurse caring for the client in labor with shoulder dystocia of the fetus should assist with positioning the client in squatting position. The client can also be helped into the hands and knees position or lateral recumbent position for birth, to free the shoulders.

A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important? A) Determining an accurate gestational age B) Asking her about the occurrence of contractions C) Checking for spontaneous rupture of membranes D) Measuring the height of the fundus

Determining an accurate gestational age Incorrect dates account for the majority of prolonged or postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. - Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? A) Dull low backache B) Malodorous vaginal discharge C) Dysuria D) Constipation

Dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and intestinal cramping with or without diarrhea.

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A) A low-lying placenta B) Fetopelvic disproportion C) Contraction ring D) Uterine bleeding

Fetopelvic disproportion The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. - A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.

The nurse would be alert for possible placental abruption during labor when assessment reveals which of the following? A) Macrosomia B) Gestational hypertension C) Gestational diabetes D) Low parity

Gestational hypertension Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology.

Amnioinfusion

Infusion of a sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression; may also be done to dilute meconium in amniotic fluid and reduce the risk that the infant will aspirate thick meconium at birth.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A) Supine B) Side-lying C) Sitting D) Knee-chest

Knee-chest Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

A group of nursing students are reviewing information about methods used for cervical ripening. The students demonstrate understanding of the information when they identify which of the following as a mechanical method? A) Herbal agents B) Laminaria C) Membrane stripping D) Amniotomy

Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical ripening. Herbal agents are a nonpharmacologic method. Membrane stripping and amniotomy are considered surgical methods.

The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention? A) Position changes B) Pain relief measures C) Immediate cesarean birth D) Oxytocin administration

Pain relief measures Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. *Oxytocin would add to the woman's already high level of pain.

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: A. Encourage ambulation every 30 minutes B. Provide pain relief measures C. Monitor the Pitocin infusion rate closely D. Prepare the woman for an amniotomy

B. as women with hypertonic uterine contractions experience a high level of pain related to the high intensity of contractions. - Providing comfort measures along with pharmacologic agents to reduce would be a priority. - Response "A" is incorrect since a woman experiencing a high level of pain secondary to contraction intensity would not feel like ambulating during this challenging time period. - Response "C" is incorrect because with this type of dystocia, augmentation of labor contractions would not be needed. If Pitocin had been infusing prior to the identification of this dystocia pattern, it would be discontinued to reduce the intensity of the contractions.

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A) Sedatives B) Tocolytics C) Oxytocins D) Corticosteroids

Oxytocins - For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. - Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. - Tocolytics would be ordered to control preterm labor. - Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

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?

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.

which postoperative intervention should a nurse perform when caring for a client who undergone cesarean birth? A. assess uterine tone and determine fundal firmness B. ensure that the client does not cough or breath deeply

a. * nurse should encoarage client to cough, perform deep-breathing excercises, and use of incentive spirometer every 2 hours

Full-term pregnant client is being assessed for induction of labor. Her bishop score is less than 6. Which order the nurse anticipate? a. insertion of foley catherer into endocervical canal b. prepare client for a cesarian birth c. administer oxytocin IV at 10 mU/minute d. artificial rupture of membrane

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

Phosphatidylglycerol

assess fetal lung activiy

After teaching a group of nursing students about risk factors associated with dystocia, the instructor determines that the teaching was successful when the students identify which of the following as increasing the risk? (Select all that apply) A) Pudendal block anesthetic use B) Multiparity C) Short maternal stature D) Maternal age over 35 E) Breech fetal presentation

c,d,e According to American College of Obstetrics and Gynecology (ACOG, 2009a), factors associated with an increased risk for dystocia include epidural analgesia, excessive analgesia, multiple gestation, hydramnios, maternal exhaustion, ineffective maternal pushing technique, occiput posterior position, longer first stage of labor, nulliparity, short maternal stature (less than 5 feet tall), fetal birth weight (more than 8.8 lb), shoulder dystocia, abnormal fetal presentation or position (breech), fetal anomalies (hydrocephalus), maternal age older than 35 years, high caffeine intake, overweight, gestational age more than 41 weeks, chorioamnionitis, ineffective uterine contractions, and high fetal station at complete cervical dilation.

this test evaluate fetal well being by monitoring fetal heart tracing

nonstress test

modified sims position

prolapsed cord

Amnioinfusion indications

• Oligohydramnios • Umbilical compression - D/T lack of amniotic fluid • To reduce FHR variable deceleration • Dilute meconium stained amniotic fluid

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: a. Stimulate uterine contractions b. Numb cervical pain receptors c. Prevent cervical lacerations d. Soften and efface the cervix

D. Prostaglandins soften and thin out the cervix in preparation for labor induction. Although they do irritate the uterus, they aren't as effective as oxytocin in stimulating contractions. Prostaglandin gel would stimulate cervical nerve receptors rather than numb them. - Prostaglandins have no power to prevent cervical lacerations.

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: A. Cervical insufficiency B. Contracted pelvis C. Maternal disproportion D. Fetopelvic disproportion

D. Fetopelvic disproportion is defined as a condition in which the fetus is too large to pass through the maternal pelvis.

After teaching a group of nursing students about tocolytic therapy, the instructor determines that the teaching was successful when they identify which drug as being used for tocolysis? (Select all that apply.) A) Nifedipine B) Terbutaline C) Dinoprostone D) Misoprostol E) Indomethacin

a, b, e Medications most commonly used for tocolysis include: - magnesium sulfate (which reduces the muscle's ability to contract) - terbutaline (Brethine, a beta-adrenergic) - indomethacin (Indocin, a prostaglandin synthetase inhibitor) - nifedipine (Procardia, a calcium channel blocker). * Dinoprostone and misoprostol are used to ripen the cervix.