LVN LEVEL III - FINAL EXAM - ANTEPARTUM

The nurse is assisting in monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be alert to which of the following maternal adverse reactions?

1. Hypertension 4. Fluid overload 5. Uterine tetany Adverse effects of oxytocin in the mother include hypertension, fluid overload, and uterine tetany. Oxytocin's antidiuretic effect increases renal reabsorption of water, leading to fluid overload — not dehydration. Jaundice and bradycardia are adverse effects that may occur in the neonate. Tachycardia — not bradycardia — is reported as a maternal adverse effect.

The nurse is caring for a client who has been diagnosed with abruptio placenta. What signs and symptoms of abruptio placenta should the nurse expect to find when she is collecting data on this client?

1. Vaginal bleeding 3. Uterine tenderness on palpation 6. Abnormal fetal heart tones Painful vaginal bleeding, uterine tenderness on palpation, and abnormal or absent heart tones are signs of abruptio placenta. Fundal height increases during abruptio placenta as a result of blood becoming trapped behind the placenta. The abdomen would feel hard and boardlike on palpation as blood permeates the myometrium and causes uterine irritability. The uterus would also be hypertonic and enlarged.

A client in labor is given meperidine (Demerol), 25 mg I.V., for labor pain. The nurse should monitor the client for which adverse effects of the drug?

2. Nausea and vomiting 3. Respiratory depression 5. Tachycardia Adverse effects of meperidine include hypotension (not hypertension), nausea, vomiting, respiratory depression, urinary retention (not urinary incontinence), tachycardia, sedation, drowsiness, and decreased uterine activity.

A client admitted with preterm labor is prescribed magnesium sulfate to halt contractions. The nurse should monitor the client for which adverse reactions to the drug?

3. Respiratory rate less than 12 breaths/minute 4. Extreme muscle weakness 5. Palpitations 6. Hot flashes The nurse should monitor the client receiving magnesium sulfate for severe hypotension (not hypertension), absent (not hyperactive) deep tendon reflexes, respiratory rate less than 12 breaths/minute, extreme muscle weakness, palpitations, hot flashes, nausea, vomiting, dizziness, and blurred vision.

An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep which of the following in mind?

A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the baby than a forceps delivery. Cephalohematomas occur more often in forceps-assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.

After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What does this finding suggest?

Abruptio placentae

Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor?

Administer oxygen through a face mask at 6 to 10 L/minute. If the client develops hypotension during the first or second stage of labor, the nurse should position the client on her left side (not supine) and administer oxygen through a face mask at 6 to 10 L/minute. Pain medication or lying supine may have caused the client's hypotension. The nurse can assist the client with breathing techniques after the hypotension has resolved.

A client in labor is receiving oxytocin (Pitocin). During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely?

Because oxytocin causes water intoxication Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe water intoxication, resulting in seizures, coma, and even death. Excessive thirst results from the work of labor and lack of oral fluids, not oxytocin administration. Oxytocin isn't toxic to the kidneys.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?

Breech position Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal rotation, extension, external rotation, and expulsion. What do these terms describe?

Cardinal movements of labor Cardinal movements of labor refer to the typical sequence of positions assumed by the fetus during labor and delivery. These positions are most commonly called descent, flexion, internal rotation, extension, external rotation, and expulsion. Phases of the first stage of labor include the latent, active, and transitional phases. Factors affecting labor include the passenger, passageway, powers, placental position and function, and psychological response. Factors that determine fetal position include the landmark of the fetal presenting part, whether the landmark faces the left or right side of the maternal pelvis, and whether the landmark faces the front, back, or side of the maternal pelvis.

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which action should be included in the plan of care?

Carefully titrating the oxytocin based on the client's pattern of labor Oxytocin may require titration to be effective; therefore, oxytocin should be titrated carefully based on the client's labor pattern. Maternal blood pressure, pulse, and respirations should be monitored every 30 to 60 minutes and with every increment of the oxytocin dose. Contraction pattern and uterine resting period should be monitored every 15 minutes. The client shouldn't be allowed to ambulate. The nurse should keep the client informed of labor progress and provide emotional support to the client and her labor partner.

During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the likely cause of these symptoms?

Eustachian tube vascularization During pregnancy, increasing levels of estrogen — not progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears.

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?

Fetal heart rate variability within an acceptable range Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 6 to 10 beats per minute is considered acceptable. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — a nonreassuring pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation.

During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority?

Ineffective tissue perfusion (cerebral) related to cord compression Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective tissue perfusion (cerebral) takes priority over the diagnoses of Deficient knowledge, Acute pain, and Risk for infection.

The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?

Intrauterine fetal death Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC.

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?

Latent phase The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsion phase.

When checking a client 1 hour after vaginal delivery, the nurse notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What do these data collection findings suggest?

Postpartum hemorrhage Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which can't occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus.

A client who is 14 weeks pregnant mentions that she has been having difficulty moving her bowels since she became pregnant. Which hormones are responsible for this common discomfort during pregnancy?

Progesterone increases smooth muscle relaxation, thereby decreasing peristalsis. This slowed movement of contents through the GI system can lead to firmer stools and constipation. Estrogen, testosterone, human chorionic gonadotropin, and human chorionic somatomammotropin don't cause constipation.

When coaching a client to push, the nurse should encourage her to use which technique?

Pushing when she feels like pushing The nurse should encourage the client to push as she feels like pushing. The nurse should monitor the client's breathing to make sure that she doesn't hold her breath for more than 5 to 7 seconds at a time. Holding her breath for prolonged periods or sustained, directed bearing down may initiate the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure. This type of bearing down is harmful during labor.

A client admitted with preeclampsia complains of a headache. When caring for a client with preeclampsia, which action is a priority?

Reducing visual and auditory stimulation A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're a lesser priority.

A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Of the following nursing diagnoses, the nurse should give the highest priority to

Risk for deficient fluid volume A ruptured ectopic pregnancy is a medical emergency because of the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from this significant blood loss. Large quantities of I.V. fluids are needed to restore intravascular volume. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss

The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?

Shallow chest breathing Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated

After an amniotomy, which client goal should take the highest priority?

The client will maintain adequate fetal tissue perfusion. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate?

The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.

The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

They're usually felt in the abdomen

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?

Transitional phase In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the cervix dilates from 5 to 7 cm, and moderate contractions progress to strong contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm, and contractions are short, irregular, and mild. No descent phase exists. (Fetal descent may begin several weeks before labor but usually doesn't occur until the second stage of labor.)

A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called:

a third-degree laceration. Delivery may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body.

Presumptive signs, such as amenorrhea and quickening,

are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators such as a fetal outline during an ultrasound confirm pregnancy.

After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Data collection reveals the following findings: Weight gain of 6 lb (3 kg), ascites, and pedal edema. These findings indicate that the client is:

demonstrating signs of hyperstimulation syndrome.

Pregnancy

increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.

Breast sensitivity

is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time.

Ketones in the urine

of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. The other laboratory values listed are all within normal limits.

A pregnant woman

should increase her caloric intake by 300 cal/day. The protein requirements (76 g/day) of a pregnant woman exceed those of a nonpregnant woman by 30 g/day. All mineral requirements, especially iron, are increased in a pregnant woman. The woman should increase her intake of all vitamins and a prenatal vitamin is usually recommended. Folic acid intake is particularly important to help prevent fetal anomalies such as neural tube defects. Intake should be increased to 800 mg/day.

To prepare a client for amniocentesis

the nurse should ask the client to empty her bladder to reduce the risk of bladder perforation. Prior to the procedure, the nurse should also assess fetal heart rate and maternal vital signs to establish baselines. The client should be asked to drink 1 L of fluid before transabdominal ultrasound, not amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, to promote venous return, and to ensure adequate cardiac output. I.V. access isn't necessary for this procedure.