mother baby chapter 21 mod 4
Bishop score
Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation, effacement, consistency, position, and station
What is the first action by the nurse to assist with the delivery of the fetal shoulders and body when there is shoulder dystocia?
Flex the mother's thighs toward her abdomen Rationale:Flexing the legs toward the abdomen allows the pelvis to open to its maximum dimension. This position is used prior to application of suprapubic pressure. Fundal pressure will not dislodge the fetal shoulders from under the bone. Placing the mother's legs in stirrups enhances visualization but will not facilitate delivery of the fetus.
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?
erratic.
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
experience of additional back pain
At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?
hospitalization, tocolytic, and corticosteroids
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?
magnesium sulfate
a nurse is developing a plan of care for a client who has preeclampsia and is receiving mag sulfate cia a continuous iv infusion. Which of the following interventions should the nurse include in the plan of care.
Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.
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?
Offer to take pictures and footprints of the infant once it is delivered.
The nurse documents the following events: crowning at 0749, fetal head emerged at 0800, McRobert's maneuver performed at 0802, suprapubic pressure applied at 0806, and fetal body delivered at 0808. What is the significance of documenting these events?
Provides an indicator of the potential for fetal compromise Rationale:Documenting this sequence of events provides an indicator of the potential for fetal compromise related to decreased oxygenation. The time of birth is when the entire body is born. The focus is on the well-being of the mother and fetus/baby, not the team's response. The Apgar score is assigned using the standard criteria.
a nurse is creating a plan of care for a client who is postpartum and adheres to traditional hispanic cultural beliefs. which of the following cultural practices should the nurse include in the plan of care?
Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.
External cephalic version contraindications
maternal problems such as uterine anomalies, uncontrolled preeclampsia, 3rd trimester bleeding, rupture membranes, oligohydramnios, hydramnios, placenta previa, vasa previa, previous c-sections, multiple gestations, nonreassuring FHR or placental inefficiencies, fetal abnormalities=IUGR or nuchal cord
A nursing student correctly identifies the most desirable position to promote an easy birth as which position?
occiput anterior
The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record?
precipitous labor
The nurse provides education to a postterm pregnant client. information will the nurse include to assist in early identification of potential problems?
"Continue to monitor fetal movements daily."
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?
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
talipes equinovarus
(clubfoot) congenital deformity of the foot in which it is plantar flexed and inverted
The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:
4000 g to 4500 g
A birth room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48 mm Hg, pulse rate 150 bpm, and mucous membranes are pale. Which interventions should be the priority for the nurse? Select all that apply.
Apply oxygen mask at 10 L/min. Discontinue the IV oxytocin infusion.
Pendulous abdomen
Characteristic of the obese with poor muscle tone and diastasis of the rectus muscles and in multiple pregnancy. The uterus bulges forward and malpresentations are common.
A full-term pregnant client is being assessed for induction of labor. Her Bishop score is less than 6. Which prescription would the nurse anticipate?
Insert a Foley catheter into the endocervical canal.
indomethacin
NSAID
The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record?
Precipitous labor
The nurse writes the above notes upon client admission. Based on this assessment the nurse anticipates which plan of care?
Prepare for an emergency 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?
Prepare the client for a cesarean birth.
What is a positive turtle sign?
The fetal head emerges and then retracts tightly against the perineal floor. Rationale:A positive turtle sign is when the head delivers and then is retracted back and rests firmly against the perineum.
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.
prodromal labor
When hypertonic uterine dysfunction occurs in EARLY labor.
amniotomy
artificial rupture of membranes
prolonged labor
dystocia
A client at 38 weeks' gestation 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
external cephalic version
external manipulation of the fetus from a breech to a vertex presentation.
prodromal labor
false labor" irregular contractions that vary in duration, intensity, and intervals and yield little or no cervical change.
A pregnant client at 42 weeks' gestation is undergoing a scheduled induction of labor based on consideration of which factors? Select all that apply.
fetal size cervical ripeness gestational age
A nulliparous woman:
has never delivered a baby.
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?
identical
When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?
keeping the communication lines open
macrosomia
large-bodied baby commonly seen in diabetic pregnancies
A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?
macrosomia
The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?
sudden shortness of breath
A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?
the 41-year-old client who conceived by in vitro fertilization
VBAC
vaginal birth after cesarean section
The nurse is caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider?
45 ml urine output in 2 hours
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:
5
The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist with the birth?
Abnormal position of the fetal head
A patient is admitted to the labor and delivery unit at 40 weeks gestation. Which of the following pieces of information collected during the patient interview would be most significant in alerting the nurse to the potential for shoulder dystocia? (Select all that apply)
Estimated fetal weight 8 lb, 13 oz (4,000 g) or more, Maternal weight gain greater than 50 lb (23 kg), Maternal height 5 ft, 3 in (160 cm) Rationale:Excessive maternal weight gain, short stature of the mother, and high estimated fetal weight are risk factors for shoulder dystocia. Ethnicity is a demographic factor not associated with this condition. Previous delivery is evidence that she is able to deliver an infant of that size, and an active phase of labor lasting 4 hours is not a significant finding.
a charge nurse on a l and d unit is teaching a newly licensed nurse how to perform leopold maneuvers. which of the following images indicates the first step of leopold maneuvers?
Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain
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?
Look for late decelerations on monitor, which is associated with fetal anoxia.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?
McRoberts maneuver
Atosiban
Oxytocin antagonist
The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?
Prepare to assist with external version.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression.
Bishop scoring system
The duration of labor is inversely cor-related with the Bishop score: a score over 8 indicates a successful vaginal birth. Bishop scores of less than 6 usu-ally indicate that a cervical ripening method should be used prior to induction
Misoprostol (Cytotec)
The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
a women in active labor suddenly experience a sharp, excruciating low abdominal pain. Which the nurse suspects may be a uterine rupture since the shape of the abd has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement?
The parents are beginning to demonstrate positive grieving behaviors.
a nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound.
To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.
Which of the following pregnancy-related conditions increase the risk for shoulder dystocia?
Uncontrolled maternal gestational diabetes Rationale:Uncontrolled gestational diabetes leads to fetal macrosomia, fat pads at the fetal neck, and increased maternal weight gain, all factors that increase the incidence of shoulder dystocia. Preeclampsia and IUGR both result in smaller infants and thus do not increase the risk of shoulder dystocia. Hyperemesis, while it can continue throughout the pregnancy, is generally a problem of the first trimester and not related to the delivery.
a nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.
a nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider.
Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.
false labor
a set of temporary contractions of the uterus that resemble the start of labor
false labor
a set of temporary contractions of the uterus that resemble the start of labor braxton hicks contractions.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
administer oxygen by mask.
A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply.
alcohol use low socioeconomic status high level of stress smoking
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?
amniotic fluid embolism
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?
amniotomy
Which action(s) will the nurse take when asked to apply suprapubic pressure during a birth with shoulder dystocia? Select all that apply.
apply downward pressure just above the pubic bone. apply pressure between contractions apply pressure at an angle toword the face of the fetus.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?
assess fetal heart sounds
nifedipine
calcium channel blocker
The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?
caput saccedaneum
Laminaria
cervical dilators
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule?
cervix dilates 1 cm per hour
Before calling the health care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the health care provider?
check for a full bladder
A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?
complications of a post-term pregnancy
cephalopelvic disproportion (CPD)
condition preventing normal delivery through the birth canal; either the baby's head is too large or the birth canal is too small
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction?
contractions most forceful in the middle of uterus rather than the fundus
A primigravida at 28 weeks' gestation comes to the clinic for a checkup. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply.
his tory of previous preterm birth current multiple gestation pregnancy uterine or cervical abnormalities.
A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?
hypotonic contractions
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight.
A nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply.
magnesium sulfate atosiban indomethacin nifedipine
A nurse is teaching a nulliparous woman at 42 weeks' gestation about labor induction, which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?
maneuvers for fetal positioning
The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?
pain relief measures
a nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect.
petechiae over the head. Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.
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?
placental abruption
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding.
The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?
prepare the client for a cesarean birth
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate?
providing a comfortable environment with dim lighting
A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which finding?
resp rate of 16 breaths a min
A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose?
tomorrow at 1400
A client with a pendulous abdomen and uterine fibroid tumors has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?
transverse lie
hypertonic uterine dysfunction
uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.
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
A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next?
Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis
Precipitous labor
Labor that lasts 3 hours or less from onset of contractions to time of delivery
Zavanelli maneuver
Zavanelli maneuver (push fetal head back into the uterus and perform cesarean delivery; high rate of both maternal & fetal mortality; last maneuver to try)
A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?
avoid any discussion of the situation with the couple.
antenatal
before birth
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status
dystocia
difficult childbirth
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?
late decelerations
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding
The nursing student demonstrates an understanding of dystocia with which statement?
"Dystocia is diagnosed after labor has progressed for a time."
Which of the following are common fetal or neonatal injuries seen after shoulder dystocia? (Select all that apply)
Asphyxia, Erb's palsy, Fractured clavicle Rationale:Erb's palsy occurs due to stretching of the brachial plexus. The clavicle or humerus may be fractured during the manipulation to free the shoulders. Asphyxia is a risk because the head is delivered in advance of the body and there is pressure on the cord and placenta, which alters fetal oxygenation. Shoulder dystocia does not cause injuries to the lower body or lower extremities, such as fractured femur or talipes equinovarus.
A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation?
Decreased fetal oxygenation
When a shoulder dystocia emergency is anticipated, what additional actions should be implemented by the nurse? (Select all that apply)
Explain to the patient and family what may happen, Put a step stool at the bedside, Have extra staff available if needed Rationale:The stool is used so the provider applying suprapubic pressure can stand directly over the patient. Extra staff is needed to implement the maneuvers used to deliver the fetal shoulders. Communicating to the patient and family about what might happen in the delivery room will help to prepare them and to decrease their anxiety. Removing the family from the delivery room is not a therapeutic response and will further increase their anxiety. A consent for a cesarean delivery is not appropriate at this time.
Shoulder dystocia is a complication of labor related to which of these factors?
Prolonged second stage of labor Rationale:Shoulder dystocia occurs when the anterior fetal shoulder gets stuck behind the mother's pubic bone. A prolonged second stage of labor is a factor related to the presence of shoulder dystocia. Uterine contractions are usually of adequate strength. The volume of amniotic fluid and the length of the active phase of labor are not risk factors for shoulder dystocia.
occiput posterior position
delivery presentation with infant's head downward and facing mothers back
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?
fetal heart tones
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
less than 3 hours
Kleihauer-Betke test
used to detect fetal blood in maternal circulation
Dystocia can be defined as: a. The carrying of an embryo or fetus. b. The process of giving birth. c. Abnormal or difficult birth. d. A birth in which the offspring enters the birth canal hind end first.
C. abnormal or difficult labor/birth
