vSim: Carla Hernandez

The provider is about to perform an amniotomy for the laboring patient to progress the delivery. The nurse assesses for risk factors of prolapsed umbilical cord. In which of the following situations is a cord prolapse more likely to occur? (Select all that apply) a- cervical dialation 1 cm b- a negative station c- estimated fetal weight of 4,000 g d- amniotic fluid 2,150 mL e- left occipitoanterior position with engagement

Answer: a- cervical dialation 1 cm b- a negative station d- amniotic fluid 2,150 mL other risk factors for umbilical cord prolapse include: amniotomy, small-for-gestation fetus, unengaged fetal part, cervical dialation less than 3 cm, malpresentation, growth restriction, prematurity, ruptured membranes with the fetus at a high station, and more than 2,000 mL of amniotic fluid (hydramnios or polyhydramnios).

amniotomy

incision into the amnion (rupture of the fetal membrane to induce labor; a special hook is generally used to make the incision) artificial rupture of membranes Amniotomy can also be performed with an oxytocin infusion to treat slow labor progress. Amniotomy, used in combination with oxytocin administration, has shown to modestly reduce the duration of labor and cesarean birth rates when compared to expectant management.

The nurse understands that which of the following potential complications could occur following an amniotomy? (Select ALL that apply) a- occult prolapsed umbilical cord b- amniotic fluid embolism c- disseminated intravascular coagulation (DIC) d- ruptured bowel e- uterine infection

Answer: a- occult prolapsed umbilical cord e- uterine infection The main potential complication following an amniotomy is umbilical cord prolapse. When the amniotic sac is ruptured, a gush of amniotic fluid could allow the umbilical cord to be compressed by the presenting part. The types of cord prolapse are occult (hidden within the uterus) or visible (the cord is seen at the vulva). Another possible complication from an amniotomy is uterine infection; thus, the nurse would promote strict sterile technique and limit the number of vaginal examinations after the procedure. The other choices are not complications from an amniotomy.

The nurse recognizes that the fetus has non-reassuring patterns following an amniotomy. What immediate interventions could the nurse perform on a patient to try to resolve this emergent issue? (Select all that apply) a-place in knee-to-chest position b- give oxygen by non-rebreather mask c- call for help from staff d- elevate the head of the bed e- provide ice chips in a cup

Answer: a-place in knee-to-chest position b- give oxygen by non-rebreather mask c- call for help from staff The nurse would implement measures to restore oxygen to the fetus through relieving compression on the umbilical cord by giving the mother additional oxygen. This can be accomplished by placing the mother into a knee-to-chest or Trendelenburg position, administering oxygen by non-rebreather mask and notifying the charge nurse and provider to help.

The nurse in labor and delivery is assisting the provider with an amniotomy. What equipment would need to be obtained and available for this procedure? (Select ALL that apply) a- urine analysis dipsticks b- fluid-impermeable pads c- blood pressure equipment d- sterile amnihook e- sterile gloves f- fetal monitoring equipment

Answer: b- fluid-impermeable pads d- sterile amnihook e- sterile gloves f- fetal monitoring equipment as well as, soap and water, washcloth, towels, clean gloves, hospital grade disinfectant wipe, and thermometer

The nurse is monitoring for adverse effects after giving nalbuphine hydrochloride (Nubain) intravenously to a woman in active labor. What are the adverse effects of this drug? (Select all that apply) a- diarrhea b- respiratory depression c- nausea and vomitting d- fetal heart rate variability decreased e- fetal heart accelerations

Answer: b- respiratory depression c- nausea and vomitting d- fetal heart rate variability decreased The adverse effects of intravenous nalbuphine hydrochloride include the following: dizziness, bradycardia, dry mouth, nausea, vomiting, respiratory depression, and diminished fetal heart rate variability. An acceleration of fetal heart rate would indicate adequate oxygenation and is not an adverse effect of nalbuphine hydrochloride. Opiod narcotics may cause constipation and not diarrhea.

A laboring patient has just received an amniotomy by her healthcare provider. Which of the following manifestations would indicate to the nurse that a complication may have resulted from this procedure? (Select all that apply) a- maternal temperature 100.2 F b- moderate variability 6 to 25 beats per minute c- fetal heart rate 102 bpm d- fetal accelerations e- variable decelerations

Answer: c- fetal heart rate 102 bpm e- variable decelerations Fetal bradycardia and variable decelerations could indicate that the presenting part is compressing the umbilical cord, and these manifestations need immediate attention by the health care provider. Fetal accelerations and moderate variability of 6 to 25 bpm are reassuring signs that the fetus is tolerating labor. A maternal temperature exceeding 100.4 F could indicate an infection

Immediately before the patient's provider performs an amniotomy, the nurse would perform which priority assessment? a- fetal biophysical profile b- maternal apical pulse c- maternal blood pressure d- fetal heart rate and pattern

Answer: d- fetal heart rate and pattern The fetal heart rate and pattern is the highest priority immediately before an amniotomy, because the fetal status needs to be monitored to ensure fetal well-being after the procedure. To ensure adquate oxygenation, the nurse compares the fetal baseline heart rate and pattern with any variations that are nonreassuring after the provider artificiially ruptures the fetal membranes. The umbilical cord could be compressed when the amniotic fluid stops providing a cushion between the presenting part and other anatomical structures.