Lewis Ch 16 Giving Birth

What are the three characteristics that distinguish true labor from false labor?

- contractions - discomfort - cervical change

Which statement regarding a teratogenic drug is incorrect? A. Teratogenic drugs cause characteristic malformation B. Teratogenic drugs act during all periods of gestation C. An increase in the dosage of teratogenic drugs increases the incidence of malformation D. An increase in the duration of exposure to teratogenic drugs increases the incidence of malformation

B. A drug is considered a teratogen if it acts during the fourth to seventh week of pregnancy, which is referred to as a specific window of vulnerability. The occurrence of characteristic malformations may prove that a drug is a teratogen. An increase in the dosage and duration of exposure to teratogenic drugs may cause an increase in malformations.

The nurse assists a client to the bathroom to void several times during the first stage of labor. Why is this an important component of nursing? A full bladder: A. is often injured during labor B. may inhibit the progress of labor C. jeopardizes the status of the fetus D. predisposes the client to urinary infection

B. A full bladder encroaches on the uterine space and impedes the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor, but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.

The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? A. Clear, dark amber colored, and containing shreds of mucus B. Straw-colored, clear, and containing little white specks C. Milky, greenish yellow, and containing shreds of mucus D. Greenish yellow, cloudy, and containing little white specks

B. By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

A nurse is caring for a 3 week old infant with hypertrophic pyloric stenosis who is severely dehydrated. What finding does the nurse expect when assessing the infant? A. Weight loss of 5% B. Severe allergic reactions C. Depressed anterior fontanel D. Urine specific gravity of 1.014

C. Depressed fontanels related to decreased cerebral spinal fluid are a classic sign of fluid volume deficiency in infants. A 5% weight loss indicates mild dehydration; a severely dehydrated infant will have a 15% weight deficit. Dehydration is unrelated to allergic reactions. This specific gravity is within the expected limits of 1.005 to 1.020.

The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first? A. Notify the practitioner B. Elevate the head of the bed C. Reposition her on her left side D. Administer oxygen by way of face mask

C. Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.

An Rh-negative mother who gave birth at 10:30 AM on Jan 7 should receive her Rh immune globulin injection no later than when? A. 10:30 AM on Jan 11 B. 10:30 PM on Jan 11 C. 10:30 AM on Jan 10 D. 10:30 PM on Jan 10

C. Rh immune globulin needs to be administered within 72 hours of delivery.

What is the best distinction between true and false labor?

The best distinction between the two is that the contractions of true labor cause progressive changes in the cervix. Effacement and dilation occur with true labor contractions.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? A. Turn her onto her left side B. Elevate the head of the bed C. Place her feet on several pillows D. Give her oxygen via face mask

A. The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase BP. Raising the head of the bed, elevating the feet, and oxygen administration will not relieve uterine compression of the large vessels.

What is the optimal nursing intervention to minimize perineal edema after an episiotomy? A. Applying ice packs B. Offering warm sitz baths C. Administering aspirin PRN D. Elevating the hips on a pillow

A. Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk of hemorrhage. Elevating the hips provides minimal perineal relief.

A client in preterm labor is to receive a tocolytic medication, and bed rest is prescribed. Which position should the nurse suggest that the client maintain while on bed rest? A. Lateral B. Supine C. Fowler D. Semi-Fowler

A. The lateral position relieves pressure on the vena cava, thereby promoting venous return and increasing placental perfusion. The supine, Fowler, and semi-Fowler positions promote hypotension because the pressure of the gravid uterus on the vena cava interferes with the return of blood from the lower extremities.

A 16 yo primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her BP is 170/110 mm Hg and she has 4+ proteinuria. She has gained 50 lb during the pregnancy, and her face and extremities are edematous. Which complication is this client experiencing? A. Eclampsia B. Severe preeclampsia C. Chronic hypertension D. Gestational hypertension

B. With severe preeclampsia, arteriolar spasms result in hypertension and decreased arterial perfusion of the kidneys. This in turn causes an alteration in the glomeruli, resulting in oliguria and proteinuria, retention of sodium and water, and edema. Eclampsia is characterized by seizures; there is no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. Hypertension that is first diagnosed during pregnancy that persists beyond the postpartum period is also considered chronic hypertension. Gestational hypertension is hypertension that first occurs during midpregnancy without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.

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. With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high BP; there is no information indicating the presence of a dangerously high BP. 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.

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time? A. Having the client empty her bladder B. Watching for signs of retained secundines C. Massaging the uterus vigorously to prevent hemorrhage D. Explaining to the client that this is a sign of uterine stablilization

A. A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. Therefore the bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not accurate.

What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline? A. Massaging the uterine fundus B. Helping the client to the bathroom C. Assessing the peripad for the amount of lochia D. Administering IM methylergonovine (Methergine) 0.2 mg

A. A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? A. Administering oxygen B. Elevating the head of the bed C. Drawing blood for a hematocrit level D. Giving an intramuscular analgesic

A. Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an IM analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a PHP's prescription.

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action should the nurse implement at this time? A. Having her pant-blow during contractions B. Placing her legs in stirrups to facilitate pushing C. Encouraging her to bear down with each contraction D. Reviewing the pushing techniques taught in childbirth classes

A. Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.

A lactating mother is administered oxytocin. What could be the function of oxytocin in the client? A. Ejection of milk B. Induction of labor C. Induction of abortion D. Control of uterine bleeding

A. Oxytocin helps in ejection of milk in lactating mothers. Induction of labor and abortion are the functions performed by oxytocin, but not in a lactating mother. Oxytocin controls uterine bleeding after the delivery.

A 26 yo G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb since her last visit, 2 weeks ago; that her BP is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? A. Mild preeclampsia B. Severe preeclampsia C. Chronic hypertension D. Gestational hypertension

A. Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia, the systolic BP is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic BP of greater than 160 mm Hg or diastolic of at least 110 mm Hg and proteinuria of 5 g or more per 24-hr specimen.

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the FHR goes up every time the fetus moves. How should the nurse respond? A. "These accelerations are a sign of fetal well-being." B. "These accelerations indicate fetal head compression." C. "Umbilical cord compression is causing these accelerations." D. "Uteroplacental insufficiency is causing these accelerations."

A. The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.

A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the client at this time? A. The cervix dilates and becomes effaced in true labor B. Bloody show is the first sign of true labor C. The membranes rupture at the beginning of true labor D. Fetal movements lessen and become weaker in true labor

A. The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movement continues unchanged throughout labor.

A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an IV fluid bolus. The client's husband asks why this is necessary. What is the best explanation? A. It is policy of the institution to provide 2 bags of LR solution B. There is a risk of hypotension, and the large amount of IV fluid reduces this risk C. Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink D. The client must be given 500 mL of fluid to ascertain that the line is patent

B. Once an epidural is initiated there is a risk of hypotension, which may result in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural medication is administered through a catheter placed by the anesthetist. Quoting institutional policy does not provide the explanation for administering the solution. Providing 500 mL of fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of determining that the line is patent before the administration of medication.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? A. Providing a plastic airway B. Controlling external stimuli C. Having emergency equipment available D. Keeping calcium gluconate at the bedside

B. Reducing lights, noise, and stimulation minimizes CNS irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? A. Hyperactive sensorium B. Increase in respiratory rate C. Lack of the knee-jerk reflex D. Development of a cardiac dysrhythmia

C. Magnesium sulfate has a depressant effect on the CNS; therefore a toxic level will be reflected by the loss of the knee-jerk reflex. The level of consciousness is decreased with excessive magnesium sulfate. There is a deceleration in the respiratory rate with magnesium sulfate toxicity. Development of a cardiac dysrhythmia may be caused by increased potassium, not magnesium sulfate.

Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy? A. A painful, tender area in the epigastric region after meals B. Lower abdominal cramping of 1 week's duration with constipation C. Leukorrhea or dysuria occurring a few days after the first missed menstrual period D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

D. A fallopian tube is unable to contain and sustain a pregnancy to term; as the fertilized ovum grows, there is excessive stretching or rupture of the affected fallopian tube, resulting in pain. At this stage the products of conception are too small to form a mass; the pain is lateral, not centered. The pain is sudden, intense, and knifelike, not prolonged or cramping. Leukorrhea and dysuria may be indicative of a vaginal or bladder infection.

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? A. Diminished bloody show B. Increased and more variable FHR C. Less discomfort with contractions D. Progressive dilation and effacement

D. Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the FHR. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.

A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? A. Empty her bladder B. Avoid eating for 8 hrs C. Take a laxative the night before the test D. Increase fluid intake for 1 hr before the procedure

D. In the first trimester when fluid fills the bladder, the uterus is pushed up towards the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The GI tract is not involved in ultrasound preparation.

While a client is being given IV magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? A. Reveals her LOC B. Reveals mobility of extremities C. Reveals response to painful stimuli D. Identifies potential for respiratory depression

D. Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL. Deep tendon reflexes do not reveal a client's level of consciousness, mobility of extremities, or the response to painful stimuli. Deep tendon reflexes can be associated with muscle strengthening.

Which type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? A. Scant alba B. Scant rubra C. Moderate rubra D. Moderate serosa

D. The uterus sloughs off the blood, tissue, and mucus of the endometrium post-delivery. This happens in three stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that is expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for the first three days following delivery. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts from day four through day 10, following delivery. Lochia alba is the final stage of lochia. Rather than blood, there will be a white or yellowish discharge that is generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around six weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than 10 days.