Maternal-Newborn Ch 22 Complications Occurring During Labor and Delivery
Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? Assess uterine tone to determine fundal firmness. Delay breastfeeding the newborn for a day. Ensure that the client does not cough or breathe deeply. Avoid early ambulation to prevent respiratory problems.
Assess uterine tone to determine fundal firmness
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).
Look for late decelerations on monitor, which is associated with fetal anoxia.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).
Look for late decelerations on monitor, which is associated with fetal anoxia.
A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. Advise the parents that the hospital can make the arrangements. Offer to pray with the family if appropriate. Leave the parents to talk through their next steps. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Respect variations in the family's spiritual needs and readiness.
Offer to pray with the family if appropriate. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Respect variations in the family's spiritual needs and readiness.
A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? Explain to her that there was probably something wrong with the infant and that is why it died. Offer to take pictures and footprints of the infant once it is delivered. Call the hospital chaplain to talk to the parents. Recommend that she not hold the infant after it is delivered so as to not upset her more.
Offer to take pictures and footprints of the infant once it is delivered.
A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient? Oxytocin therapy Fluid replacement Pain management Increasing activity
Oxytocin therapy
The pregnant mother who has had no prenatal care comes to the labor and delivery department with ruptured membranes. The history of group B streptococcus (GBS) is unknown. The mother states she has no known drug allergies. The nurse will prepare to administer which drug to this mother? Penicillin G Vancomycin Cefdinir Doxycycline
Penicillin G
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? Genetic abnormality Premature rupture of membranes Preeclampsia Placental abruption
Placental abruption
The nurse is caring for a mother experiencing precipitous labor. The nurse continues to assess this mother for which serious complication? Placental abruption Uterine rupture Eclampsia Cord prolapse
Placental abruption
The first signs of uterine rupture may include some of the following:
Sudden development of a category II or III fetal heart rate pattern, often bradycardia, possibly preceded by decelerations Maternal hemodynamic instability manifested by hypotension and tachycardia Weakening contractions, as detected by palpation or internal monitoring Loss of fetal stations (a fetus that is +3, for example, may rise to station 0) Abdominal pain Vaginal bleeding or hematuria
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? Apologize and tell her that the photos will be destroyed immediately. Console her with the fact that she has other children. Tell her that the hospital will keep the photos for her in case she changes her mind. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.
Tell her that the hospital will keep the photos for her in case she changes her mind.
The nurse is teaching the mother about surgical incisions for a cesarean birth. What reason would the nurse give to the mother as to why a low transverse incision is preferable? The wound will be stronger. It requires less sutures. It leaves a better scar. There's less chance of bleeding.
The wound will be stronger.
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? Use McRoberts maneuver. Use Zavanelli maneuver. Apply pressure to the fundus. Attempt to push in one of the fetus's shoulders.
Use McRoberts maneuver
The nurse is assessing a patient in labor. On which complication of labor as identified within the 2020 National Health Goals will the nurse focus? Uterine rupture Prolapsed fetal cord Hypotonic contractions Hypertonic contractions
Uterine rupture
The nurse is evaluating the fetal heart rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability? Variability is absent. Variability is minimal. Variability is normal. Variability is marked.
Variability is normal
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: administer oxygen by mask. increase her intravenous fluid infusion rate. put firm pressure on the fundus of her uterus. tell the woman to take short, catchy breaths.
administer oxygen by mask.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? placental separation aspiration amniotic fluid embolism congestive heart failure
amniotic fluid embolism
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? applying suprapubic pressure against the fetal back continuing to monitor maternal and fetal status noting the space at the maternal umbilicus auscultating the fetal heart rate at the level of the umbilicus
continuing to monitor maternal and fetal status
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? well coordinated. poor in quality. brief. erratic.
erratic.
The mother comes to her prenatal appointment. She tells the nurse that it feels like the baby is kicking on her bladder and it is harder to breathe. The nurse suspects the fetus is in breech position. Which procedure would the nurse implement to determine the position of the baby? Leopold maneuvers McRoberts maneuver Rubin maneuver Gaskin maneuver
Leopold maneuvers
A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse most likely include as the most common? macrosomia breech presentation persistent occiput posterior position multifetal pregnancy
persistent occiput posterior position
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to: place a hand gently on the fetal head to guide birth. ask her to push with the next contraction so birth is rapid. assess blood pressure and pulse to detect placental bleeding. attach a fetal monitor to determine fetal status.
place a hand gently on the fetal head to guide birth
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question? "Maybe your uterus is just tired and needs a rest." "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." "Maybe your baby has developed hydrocephaly and the head is too swollen." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
The laboring mother is 8 cm dilated and continues to want to push with every contraction. The mother asks the nurse why she can't push. What is the nurse's best response? "If you push against the cervix it will cause it to swell." "You have to wait until you are fully dilated to push." "Pushing before it's time won't get the baby her any sooner." "The baby is not down far enough for you to push."
"If you push against the cervix it will cause it to swell."
Four hours after delivery a mother suddenly complains of not being able to breathe and is gasping for breath. The nurse administers oxygen and calls for help. Which type of oxygen delivery device would be most appropriate for the nurse to utilize? Non rebreather mask Venturi mask Face mask Nasal cannula
Non Rebreather mask
A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem? The fetus is macrosomic. The mother is fighting the contractions. The mother has a small pelvic opening. Uterine contractions are weak and ineffective.
Uterine contractions are weak and ineffective.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? Uterine rupture Hypertonic uterus Placenta previa Umbilical cord compression
Uterine rupture
A cord prolapse may be overt or occult.
With an overt prolapse, the cord slips out of the vagina ahead of the fetus With an occult prolapse, the cord is descending next to the fetus and becomes entrapped between the fetus and the maternal parts.
A nurse is conducting an in-service program for a group of labor and birth unit nurses about cesarean birth. The group demonstrates understanding of the information when they identify which conditions as appropriate indications? Select all that apply. active genital herpes infection placenta previa previous cesarean birth prolonged labor fetal distress
active genital herpes infection placenta previa previous cesarean birth fetal distress
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? first degree second degree third degree fourth degree
fourth degree
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: longer lengths of labor. increased number of overall pregnancies. increasing birth weight. poor quality of prenatal care.
increasing birth weight.
When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? superficial structures above the muscle through the perineal muscles through the anal sphincter muscle through the anterior rectal wall
through the anal sphincter muscle
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? providing a comfortable environment with dim lighting administering oxytocin preparing the woman for an amniotomy encouraging the women to change positions frequently
providing a comfortable environment with dim lighting
A biophysical profile has been completed on a pregnant woman. The nurse interprets which score as normal? 9 7 5 3
9
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? If the woman has a full bladder, labor may be uncomfortable for her. If the woman's bladder is distended, it may rupture. A full rectum can cause diarrhea. A full bladder or rectum can impede fetal descent.
A full bladder or rectum can impede fetal descent.
amniotic fluid embolism
An extremely rare, life-threatening condition that occurs when amniotic fluid and fetal cells enter the pregnant woman's pulmonary and circulatory system through the placenta via the umbilical veins, causing an exaggerated allergic response from the woman's body
The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation. Assessment reveals prolapsed fetal cord. Which action should the nurse prioritize? Turn client to her left side. Place client in a knee-chest position. Use fingers to press upward on the presenting part. Prep for immediate cesarean delivery.
Use fingers to press upward on the presenting part.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage infection depression pulmonary emboli
infection
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? supine side-lying sitting knee-chest
knee-chest
TOLAC
trial of labor after cesarean
The nurse is teaching an antepartum class to first-time mothers. A mother asks the nurse if she should stay in bed when her contractions start. How should the nurse respond? "No, walking actually shortens the first stage of labor." "No, but you need to only walk for 15 minute intervals." "Yes, you don't want to risk having your water break while you are walking." "Yes, it is important so monitoring can be done for you and the baby."
No, walking actually shortens the first stage of labor."
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: longer lengths of labor. increased number of overall pregnancies. increasing birth weight. poor quality of prenatal care.
increasing birth weight.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? The client is having a moderate amount of rubra lochia. The client requires assistance to ambulate in the hallway. The fundus is located 2 fingerbreadths above the umbilicus. The client is afibrile. Bowel sounds are active.
The fundus is located 2 fingerbreadths above the umbilicus
The labor and delivery nurse would identify that which women are more likely to experience dystocia during labor? Select all that apply. A mother having her first baby A mother having her 10th baby A mother having elective induction A diabetic mother An Asian mother
A mother having elective induction A diabetic mother An Asian mother
A mother in the active phase of labor has been contracting for 4 hours. The contractions are occurring infrequently and not lasting very long. When the nurse palpates the uterus during a contraction it feels soft. The nurse should anticipate receiving which prescription from the obstetric provider? Administer oxytocin Place in side-lying position Prepare for epidural anesthesia Obtain internal monitoring
Administer oxytocin
A mother in labor with ruptured membranes comes to the labor and delivery unit. It is determined that the fetus is in a single footling breech presentation. The nurse assesses the mother for which complication associated with this fetal position? Cord prolapse Uterine atony Placental abruption Brachial plexus injury
Cord prolapse
The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? Shorter dilatational stage of labor Experience of additional back pain Need to have the baby manually rotated Necessity for vacuum extraction for birth
Experience of additional back pain
The nurse is caring for a woman at 32 weeks' gestation who expresses deep concern because her previous pregnancy ended in a stillbirth. The nurse would encourage the mother to have what screening test? Nonstress test (NST) Contraction stress test Vaginal ultrasound Doppler ultrasound
Nonstress test (NST)
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? Place the client in lithotomy position for birth. Administer oxytocin intravenously at 4 mU/minute. Perform artificial rupture of membranes. Prepare the client for a cesarean birth.
Prepare the client for a cesarean birth
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? Place the client in lithotomy position for birth. Administer oxytocin intravenously at 4 mU/minute. Perform artificial rupture of membranes. Prepare the client for a cesarean birth.
Prepare the client for a cesarean birth.
The nurse would prepare a client for amnioinfusion when which action occurs? Severe variable decelerations occur and are due to cord compression. Fetal presenting part fails to rotate fully and descend in the pelvis. The fetus shows abnormal fetal heart rate patterns. Maternal pushing is compromised due to anesthesia.
Severe variable decelerations occur and are due to cord compression.
A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? external cephalic version trial labor forceps birth vacuum extraction
external cephalic version
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 low-lying placenta fetopelvic disproportion contraction ring uterine bleeding
fetopelvic disproportion
A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? labor less than 3 hours hemoglobin of 11.5 mg/dL placenta removed via manual extraction multiparity
placenta removed via manual extraction
Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? "I will make handprints and footprints of the baby for you to keep." "I know you are hurting, but you can have another baby in the future." "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" "Have you named your baby yet? I would like to know your baby's name."
"I know you are hurting, but you can have another baby in the future."
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambuate until the next day. What response by the nurse is most appropriate? "If you do not get up to walk you will not recover." "Walking is the best way to prevent complications such as blood clots." "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." "Maybe you will feel better after you take pain medication."
"Walking is the best way to prevent complications such as blood clots."
The fetus of a pregnant patient is in a breech presentation. Where will the nurse auscultate fetal heart sounds? Low in the abdomen Left lateral abdomen High in the abdomen Right lateral abdomen
High in the abdomen
The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus? Shoulder dystocia Umbilical cord prolapse Nuchal cord Breech position
Shoulder dystocia
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? "If you do not get up to walk you will not recover." "Walking is the best way to prevent complications such as blood clots." "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." "Maybe you will feel better after you take pain medication."
Walking is the best way to prevent complications such as blood clots."
There are several women in active labor on the unit. Which woman is at highest risk for developing hypotonic contractions and therefore will need frequent nursing assessments? a 21-year-old primipara woman who does not have a support person with her and is very anxious a 17-year-old primipara requesting more pain medication every 15 to 30 minutes (and not receiving it) even though there is an epidural catheter in place that is working effectively a G4 P3 client who is having twins and wants to experience a "natural birth" a 37-year-old G2 P1 woman being induced whose last ultrasound at 36 weeks' gestation showed oligohydramnios
a G4 P3 client who is having twins and wants to experience a "natural birth"
