Chapter 16 - Dysfunctional Labor

34. Which patient is most at risk for a uterine rupture? a. A gravida 4 who had a classic cesarean incision b. A gravida 5 who had two vaginal births and one cesarean birth c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

. A gravida 4 who had a classic cesarean incision

classical c-section incision risk

A classical C-section incision is made at the top of the uterine fundus, which contracts most strongly. An incision in this area increases the chances of uterine rupture

Which dysfunctional labor condition may require operative birth? Select all that apply. One, some or all responses may be correct. Psychological distress Abnormal fetal heart rate patterns Fetal acidosis Uterine overdistention Meconium passage

Abnormal fetal heart rate patterns Fetal acidosis Meconium passage ------------------------------------- Uterine overdistention comes with multiple gestation or polyhydramnios and can cause ineffective contractions but does not require an operative birth.

Which action by the nurse is used to manage labor dystocia?

Aid position changes - help to progress the descent of the fetus

Which client factor increases the risk of preterm labor? Primigravida Assisted reproduction Advanced maternal age Oral contraceptives

Assisted reproduction - there is a risk of preterm labor with assisted reproduction since there is a higher chance of multifetal gestation

5. Which technique is least effective for the patient with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees

B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

Which response does a patient's body give to the stress of labor? Decreased glucose consumption Decreased pain perception Decreased blood supply to the uterus and placenta Decreased resistance of abdominal and pelvic muscles

Decreased blood supply to the uterus and placenta

Which pelvic shape would allow for the most vaginal births? Gynecoid Anthropoid Android Platypelloid

Gynecoid

Which action by the nurse would reduce the risk for intrauterine infection? Limit vaginal examinations. Reduce vaginal examination's duration. Keep under pads for the patient moist and warm. Clean excess secretions from the vaginal area in a back to front direction.

Limit vaginal examinations.

Which element would the nurse assess to identify a possible Triple I infection? Maternal temperature Amniotic fluid for clear color and mild odor High amniotic fluid glucose Maternal hematocrit and hemoglobin levels

Maternal temperature

Which maternal condition is a possible sign of infection during dysfunctional labor? Temperature of 38° C and heart rate of 140 bpm White blood cell count of 10,000 and purulent fluid from cervix Oral temperature of 39.0° C and white blood cell count of 18,000 Heart rate of 180 bpm and cloudy cervical discharge

Oral temperature of 39.0° C and white blood cell count of 18,000 WBC range: 5k-10k

Which intervention would the nurse initiate for a patient with labor dystocia? Administer low-dose epidural analgesia. Decrease oxytocin. Administer a tocolytic medication. Provide oral fluids.

Provide oral fluids.

Which action by the nurse would assist the patient with a rapid precipitous labor? Advocate for an epidural block. Provide oxygen to the patient. Increase oxytocin administration. Lay the patient flat.

Provide oxygen to the patient. --------------------------------------- increasing oxytocin administration would only decrease oxygen supply further

Which criteria of the fetus would require hospitalization after preterm premature rupture of the membranes (PPROM)? Fetal presentation has changed. Viability of the fetus has been reached. The fetus is less than 20 weeks gestation. Fetal activity decreases at night.

Viability of the fetus has been reached. The fetus past 20 weeks is most likely to survive outside of the womb and experience more complications as a result of a pre-term birth

15. A patient who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "You should come into the office and let the doctor check you." b. "Acetaminophen is acceptable during pregnancy. You should not take aspirin, however." c. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."

a. "You should come into the office and let the doctor check you." constant back pain is a key sign of preterm labor. The patient must be assessed for preterm labor before pain meds

Which step would the nurse recommend to the laboring client for effective pushing?

sit upright and lean forward

VBAC has a greater risk for?

uterine rupture

Which initial sign would indicate the occurrence of shoulder dystocia? Slow descent of the fetus Retraction of the head against the perineum Uncoordinated and erratic contraction High uterine resting tone

Retraction of the head against the perineum

What risks are associated with preterm labor?

Risks associated with preterm labor: - placental abruption - stress - infection **

6. Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.

ANS: A Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.

Which therapeutic intervention during preterm labor would act as a neuroprotectant for the fetus? Use of supplemental oxygen during labor Administration of magnesium sulfate Placement of cerclage Supplementation of folic acid

Administration of magnesium sulfate - protects the fetus from cerebral palsy

Which action would assist a fetal presentation of rotation during labor?

Assist in fetal presentation of rotation: 1. forceps 2. side-lying or hands-and-knees position 3. Cesarean birth may be necessary

3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2°C (99°F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates

C Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38°C (100.4°F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

Which client information would guide the care plan of an extremely preterm infant following delivery? Is a multigravida Has a diagnosis of hypothyroidism Has received corticosteroids Blood type is Rh negative

Has received corticosteroids

Which manifestation would a baby likely experienced from a precipitous birth? Select all that apply. One, some, or all responses may be correct. Hypoxia Intracranial hemorrhage Nerve damage High Apgar score Jaundice

Hypoxia (shortened contractions may mean not enough gas exchange at the placenta) Intracranial hemorrhage Nerve damage (all due to the sudden release of pressure)

Chorionic villi invade myometrium Implantation of the placenta into the uterine wall

Increta - chorionic villi invade myometrium Accreta - implantation of the placenta into the uterine wall Percreta - Complete perforation through uterine musculature

Which symptom is an indication of Triple I infection? Select all that apply. One, some, or all responses may be correct. Maternal fever Vaginal spotting Decreased urinary output Labored respirations Uterine tenderness

Maternal fever Uterine tenderness

Which procedure would be used to correct shoulder dystocia during childbirth? Fundal pressure McRobert's maneuver Medication administration Gravity assistance

McRobert's maneuver

Which condition would the nurse monitor for after a prolonged labor? Select all that apply. One, some, or all responses may be correct. Neonatal infection Maternal exhaustion Maternal infection Maternal hemorrhage High levels of maternal fear

Neonatal infection Maternal exhaustion Maternal infection High levels of maternal fear

Which intervention would be used to prevent premature cervical dilation? Place a cerclage. Insert an intrauterine device. Insert a Foley catheter. Use a vaginal diaphragm.

Place a cerclage

Which criterion would help the nurse confirm Triple I infection? Select all that apply. One, some, or all responses may be correct. Placenta inflammation and elevated maternal temperature Elevated maternal temperature Positive Gram stain for bacteria and elevated maternal temperature Elevated maternal temperature and high amniotic fluid glucose Fetal tachycardia and elevated maternal temperature

Placenta inflammation and elevated maternal temperature Positive Gram stain for bacteria and elevated maternal temperature

Which outcome would the nurse prepare for during labor and delivery of a multifetal pregnancy? Vaginal birth Placental shearing Laboring in a supine position Delivery of twins typically at 34 weeks

Placental shearing

Post-term pregnancy Complication Nursing consideration S/s

Post-term pregnancy: beyond 41 weeks Complications: placental insufficiency, meconium aspiration The nurse must know the EDD + 2 weeks Oligohydramnios is a possible sign

Which client is at the greatest risk for a uterine rupture? Receiving oxytocin for labor induction With a nulliparous singleton pregnancy Who experienced a premature rupture of membranes With oligohydramnios

Receiving oxytocin for labor induction

For which reason may multifetal pregnancies result in dysfunctional labor? Placental abruption Infection Soft tissue obstruction Uterine overdistention

Uterine over distention - the uterus does not contract properly, which may lead to hypoxia or postpartum hemorrhage

1. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area

a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent f. Insertion of cord back into vaginal area

32. Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction

a. Complaint of pain between the scapulae

8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

a. Incomplete uterine relaxation a high uterine contraction tone with inadequate relaxation reduces blood flow to the placenta and decreases fetal oxygen supply. Maternal sedation will sedate the fetus, but it will not decrease blood flow

12. A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the patient with her hips slightly elevated.

a. Notify the health care provider promptly.

33. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and +2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and +2. What is the nurse's next action? a. Palpate the patient's bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.

a. Palpate the patient's bladder for fullness. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void.

9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. palpate the infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.

a. palpate the infant's clavicles.

30. When reviewing the prenatal record of a patient at 42 weeks' gestation, the nurse recognizes that induction of labor is based upon which indication a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-lb weight gain at each of the last two weekly visits.

a. reduced amniotic fluid volume.

19. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the patient not to push until you prepare the vacuum extraction device for physician. d. Reposition the patient to facilitate birth

b. Ask the physician if he or she would like you to prepare for a surgical method of birth.

25. Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern

b. Fetal distress

1. Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid

b. Gynecoid

28. Which finding would be indicative of an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL

b. Heart rate of 122 bpm

24. A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks' gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient's request? a. There is no way to tell if any complications would arise. Because the patient is not presenting with any problems, the nurse should call the health care provider and inform her or him of the patient's decision to go home and wait. b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the patient that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the patient will be sent home. d. Tell the patient that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physician's directions.

b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting.

23. A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care? a. Administration of antihypertensive medication b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring

b. Initiation of CPR and other life support measures Anaphylactoid syndrome - when amniotic fluid enters maternal pulmonary circulation which can lead to shock and hypotension - CPR, mechanical ventilation and blood-component therapy

2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor

b. Keeping underpads and linens as dry as possible ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

2. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction

b. Painful uterine contractions c. Increased resting tone e. Increased uterine pressure

4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.

b. Perform a vaginal examination A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

31. Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hour c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/minute

b. Urine output >30 mL/hour

14. The fetus in a breech presentation is often born by cesarean birth because a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the patient delivers vaginally.

b. compression of the umbilical cord is more likely. After the fetal legs and trunk emerge from the patient's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of the fetus.

22. A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent

c. Cesarean section

20. A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test? a. Patient must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Patient should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.

c. Patient should refrain from sexual activity prior to testing. sexual activity or cervical manipulation can cause a false-positive in a fetal fibronectin test

27. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/minute. b. Stop the Pitocin infusion. c. Position the patient in the knee-chest position. d. Increase the main line infusion to 150 mL/hour.

c. Position the patient in the knee-chest position.

13. Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of -3 d. Meconium-stained amniotic fluid

c. Presenting part at a station of -3

36. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency

c. Prolonged use of oxytocin postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle become fatigued and do not contract properly

10. A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "Let me take off the monitor belts and help you get into a more comfortable position." c. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."

d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps." Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation.

7. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous patient with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous patient at 39 weeks of gestation who is expecting twins

d. A multiparous patient at 39 weeks of gestation who is expecting twins

17. Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.

d. Contractions abruptly stop during labor. A large rupture of the uterus will disrupt its ability to contract

16. Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure

d. Fetal heart rate, maternal pulse, and blood pressure

18. Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the patient for epidural administration as ordered by the physician

d. Preparing the patient for epidural administration as ordered by the physician The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone

26. Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at -3 station

d. Presenting part at -3 station If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely;

35. A pregnant woman develops hypertension. The nurse monitors the patient's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow

d. Reduced placental blood flow

11. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.

d. Reposition the mother with her hips higher than her head. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete.

21. An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks' gestation and has two other children at home, ages 3 and 6. The patient's husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal? a. The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient's next scheduled antepartum visit the following week. b. The patient and husband will hire a nanny to act as an additional caregiver for the next month. c. The patient will continue to take care of her children at home, taking frequent rest periods. d. The patient and husband will make arrangements for childcare routine activity assistance for the rest of the pregnancy.

d. The patient and husband will make arrangements for childcare routine activity assistance for the rest of the pregnancy.

Which secondary effect would dehydration have on the pregnant client? Urinary retention Uterine irritability Vaginal bleeding Peripheral edema

uterine irritability - insufficient fluids and electrolytes cause muscle cramping of the uterus. This may cause early contractions which may lead to preterm labor