OB: Pregnancy, Labor, Childbirth, Postpartum - At Risk

Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process? 1. "It's such a tiny baby." 2. "Do you think he'll make it?" 3. "Why does he need to be in an incubator?" 4. "My baby looks so much like my husband."

1. "It's such a tiny baby." Rationale: By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.

Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding between this mother and her newborn? 1. Having the mother feed the infant 2. Removing the infant from the mother's arms if it cries 3. Positioning the infant so its head rests on the mother's shoulder 4. Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant

1. Having the mother feed the infant Rationale: Feeding the infant promotes bonding through physical interaction, and positioning the infant in a face-to-face position facilitates eye contact. Removing the infant decreases the pair's time together. Positioning the infant on the mother's shoulder prevents the face-to-face contact that promotes bonding. It is important to have the parent and infant interact as soon as possible after birth to promote bonding.

For which complication would a client who has had a spontaneous abortion be assessed? 1. Hemorrhage 2. Dehydration 3. Hypertension 4. Subinvolution

1. Hemorrhage Rationale: Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.

Which complication is the result of type 1 diabetes in a pregnant client? 1. Increased risk of hypertensive states 2. Abnormal placental implantation 3. Excessive weight gain because of increased appetite 4. Decreased amount of amniotic fluid as the pregnancy progresses

1. Increased risk of hypertensive states Rationale: The likelihood of gestational hypertension increases fourfold in the client with diabetes mellitus, probably because of a preexisting vascular disorder. Abnormal implantation occurs because of scarring or uterine abnormalities, not because of diabetes. Most pregnant women have an increased appetite; excessive weight gain may be caused by a macrosomic fetus and hydramnios. More than 2000 mL of amniotic fluid (hydramnios, polyhydramnios) is associated with diabetes; its exact cause is unknown. It also occurs with major congenital fetal anomalies, Rh sensitization, and infections (e.g., syphilis, toxoplasmosis, cytomegalovirus, herpes, and rubella).

Which is a consequence on the neonate of maternal smoking during pregnancy? 1. Low birth weight 2. Facial abnormalities 3. Chronic lung problems 4. Hyperglycemic reactions

1. Low birth weight Rationale: Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in an SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.

A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8°F (38.2°C), chills, and malaise. Which condition would the nurse suspect? 1. Mastitis 2. Engorgement 3. Blocked milk duct 4. Inadequate milk production

1. Mastitis Rationale: Because of the presence of generalized symptoms, the nurse would suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? 1. Mild preeclampsia 2. Severe preeclampsia 3. Chronic hypertension 4. Gestational hypertension

1. Mild preeclampsia Rationale: Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure 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 blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.

Which is the priority nursing intervention during the admission of a primigravida in labor? 1. Monitoring the fetal heart rate 2. Asking the client when she ate last 3. Obtaining the client's health history 4. Determining whether the membranes have ruptured

1. Monitoring the fetal heart rate Rationale: Determining fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured, may be taken once fetal well-being has been established.

Which factor will increase the risk for hypotonic uterine dystocia in a postpartum client? 1. Twin gestation 2. Gestational anemia 3. Hypertonic contractions 4. Gestational hypertension

1. Twin gestation Rationale: A multiple gestation thins the uterine wall by overstretching it; therefore the efficiency of contractions is reduce. Gestational anemia is physiological anemia that is benign; although anemia may cause fatigue during labor, it does not affect uterine contractility. Hypertonic contractions will cause increased discomfort, fatigue, dehydration, and increased emotional distress, not hypotonic uterine dystocia. Therapeutic interventions include rest and sedation. Gestational hypertension may trigger preterm labor; it does not cause hypotonic uterine dysfunction.

Which test is used to confirm cephalopelvic disproportion? 1. Ultrasound 2. Fetal scalp pH 3. Amniocentesis 4. Digital pelvimetry

1. Ultrasound Rationale: A sonogram of the pelvis is an accurate and safe test for cephalopelvic disproportion. Fetal scalp pH is performed to assess fetal well-being. Amniocentesis is a test of the components of the amniotic fluid; it does not reveal the size of the fetus or the diameter of the pelvis. Digital pelvimetry is an external measurement obtained by the primary health care provider; it is an estimate, not an accurate assessment, and is used less commonly than ultrasound.

A client at 36 weeks' gestation has a blood pressure of 140/90. Which additional sign of preeclampsia would the nurse assess for? 1. Urine dipstick positive for protein 2. Mild ankle edema 3. Episodes of dizziness on arising 4. Weight gain of 2 lb (907 g) in 2 weeks

1. Urine dipstick positive for protein Rationale: Preeclampsia is characterized by increased blood pressure and proteinuria. Mild ankle edema, known as physiological edema, is commonly seen in the third trimester. Although no longer a diagnostic criterion for preeclampsia, edema evidenced by excessive weight gain or edema of the hands and face may support the diagnosis. Episodes of dizziness on arising may occur in the third trimester because the enlarged uterus impedes venous return, causing supine hypotension. Weight gain of 2 lb in 2 weeks is expected during the third trimester.

Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? 1. Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. 2. Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. 3. Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. 4. Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.

1. Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. Rationale: In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intra-abdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs and uterine perfusion decreases in the standing and sitting positions.

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action? 1. Calling the primary health care provider 2. Changing the maternal position 3. Obtaining the maternal blood pressure 4. Preparing the environment for an immediate birth

2. Changing the maternal position Rationale: The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.

The nurse admits a client with preeclampsia to the high-risk prenatal unit. Which is the next nursing action after the vital signs have been obtained? 1. Calling the primary health care provider 2. Checking the client's reflexes 3. Determining the client's blood type 4. Establishing an intravenous (IV) line

2. Checking the client's reflexes Rationale: The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary health care provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary health care provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment.

Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction? 1. Back blows 2. Chest thrusts 3. Suprapubic thrusts 4. Abdominal thrusts

2. Chest thrusts Rationale: Chest thrusts are performed for an obstetrical client with a foreign airway body obstruction. Back blows, suprapubic thrusts, or abdominal thrusts are not used to dislodge a foreign body causing airway obstruction.

Which postpartum client would the nurse assess first? 1. Client who vaginally delivered a 7-lb (3175 g) baby 1 hour ago 2. Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago 3. Client who vaginally delivered a preterm baby 4 hours ago 4. Client who had a planned cesarean delivery of an 8-lb (3629 g) baby 2 hours ago

2. Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago Rationale: The nurse would assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9 lb; 4082 g) can result in uterine atony. Delivering a 7-lb baby (3175 g) or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.

Why is a multiple-gestation pregnancy considered a high risk? 1. Postpartum hemorrhage is an expected complication. 2. Perinatal mortality is two to three times more likely in multiple than in single births. 3. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. 4. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

2. Perinatal mortality is two to three times more likely in multiple than in single births. Rationale: Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increase the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

After an incomplete abortion, a client asks the nurse to tell her again what is meant by an "incomplete abortion." Which response by the nurse is appropriate? 1. "I don't think you should focus on this anymore." 2. "It's when the fetus dies but is retained in the uterus for at least 2 months." 3. "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." 4. "I think it's best for you to ask your primary health care provider for the answer to that question."

3. "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." Rationale: A correct and simple definition answers the question and fulfills the client's need to know. Telling the client not to focus on the topic anymore denies the client's right to know. The definition of a missed abortion is when the fetus dies but is retained in the uterus for at least 2 months. Telling the client to ask her primary health care provider for the answer is an abdication of the nurse's responsibility; the nurse can independently reinforce information and correct misconceptions.

Between which weeks of gestation would a client with type 1 diabetes expect to increase her insulin dosage? 1. 10th and 12th weeks of gestation 2. 18th and 22nd weeks of gestation 3. 24th and 28th weeks of gestation 4. 36th and 40th weeks of gestation

3. 24th and 28th weeks of gestation Rationale: At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases, and insulin needs decrease accordingly.

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with her or his own feelings regarding abortion, death, and loss to be able to do which? 1. Maintain control of the situation 2. Share personal grief with the client 3. Allow the client to express her grief 4. Teach the client how to cope effectively

3. Allow the client to express her grief Rationale: The nurse can be more sensitive to the needs of the client by addressing personal emotions first. Control is not, and should not be, the goal of the nurse. The client's feelings, not the nurse's, should be the focus. A time of crisis is not the time to teach; the client is not ready to learn.

A client is admitted at 40 weeks' gestation with her cervix dilated 5 cm and 100% effaced, the presenting part at station 0, and fetal heart tones heard just above the umbilicus. Which fetal presentation is indicated by these assessment findings? 1. Face 2. Brow 3. Breech 4. Shoulder

3. Breech Rationale: In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.

When a fetus is in a footling breech presentation, the nurse plans and implements care with which consideration in mind? 1.Severe back discomfort will occur. 2. Length of labor usually is shortened. 3. Cesarean birth probably will be necessary. 4. Meconium in the amniotic fluid is a sign of fetal hypoxia.

3. Cesarean birth probably will be necessary. Rationale: A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation, because contractions compress the fetal intestinal tract, causing release of meconium.

The nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On which information about pregnancy and diabetes would the nurse base the response? 1. Taking exogenous insulin stimulates fetal growth. 2. Consuming more calories covers the insulin secreted by the fetus. 3. Extra circulating glucose causes the fetus to acquire fatty deposits. 4. Fetal weight gain increases as a result of the common response of maternal overeating.

3. Extra circulating glucose causes the fetus to acquire fatty deposits. Rationale: It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, where it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

A pregnant client with a history of preterm labor is at home on bed rest. Which instruction would be included in this client's teaching plan? 1. Place blocks under the foot of the bed. 2. Sit upright with several pillows behind the back. 3. Lie on the side with the head raised on a small pillow. 4. Assume the knee-chest position at regular intervals throughout the day.

3. Lie on the side with the head raised on a small pillow. Rationale: Bed rest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion. The Trendelenburg position is used when the cord is prolapsed or the client is in shock. Sitting up in bed increases pressure on the cervix and could lead to further dilation. Assuming the knee-chest position at regular intervals throughout the day may help relieve pressure of the fetus on the cervix; however, it will not enhance uterine perfusion.

Which cardiac disease has the lowest risk for maternal mortality? 1. Endocarditis 2. Aortic stenosis 3. Patent ductus arteriosus 4. Pulmonary hypertension

3. Patent ductus arteriosus Rationale: A client with patent ductus arteriosus has the lowest risk for maternal mortality. A client with aortic stenosis has a higher risk of maternal mortality. A client with endocarditis or pulmonary hypertension has the highest risk of maternal mortality.

The nurse teaches a client who is about to undergo an amniocentesis that ultrasonography will be performed just before the procedure to determine which? 1. Gestational age of the fetus 2. Amount of fluid in the amniotic sac 3. Position of the fetus and the placenta 4. Location of the umbilical cord and placenta

3. Position of the fetus and the placenta Rationale: The position of the fetus and placenta is located by means of ultrasonography to assist in preventing trauma from the needle during the amniocentesis. Although ultrasonography can be used to determine gestational age, this is not its purpose before an amniocentesis. Determining the amount of fluid in the amniotic sac is not the purpose of ultrasonography just before an amniocentesis. The position of the placenta and fetus, not just the cord and the placenta, is needed for safe introduction of the needle.

Which factor contraindicates sexual intercourse during pregnancy? 1. Fetal tachycardia 2. Presence of leukorrhea 3. Premature rupture of membranes 4. Imminence of the estimated date of birth

3. Premature rupture of membranes Rationale: Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.

Which preexisting condition necessitates a cesarean birth? 1. Gonorrhea 2. Chlamydia 3. Chronic hepatitis 4. Active genital herpes

4. Active genital herpes Rationale: Once the membranes have ruptured, an active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, Chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacological.

Which is a primary focus of teaching for a pregnant adolescent at her first prenatal clinic visit? 1. Instructing her about the care of an infant 2. Informing her of the benefits of breast-feeding 3. Advising her to watch for danger signs of preeclampsia 4. Encouraging her to continue regularly scheduled prenatal care

4. Encouraging her to continue regularly scheduled prenatal care Rationale: It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.

Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system? 1. Increased pressure is placed on the veins. 2. Intra-abdominal pressure is significantly increased. 3. The blood flow to the heart is decreased considerably. 4. Extravascular fluid is remobilized into the vascular compartment.

4. Extravascular fluid is remobilized into the vascular compartment. Rationale: During the immediate period after birth the extravascular fluid is remobilized into the vascular compartment, increasing the client's risk for cardiac decompensation. At the moment of birth, the pressure on the veins is removed, the intra-abdominal pressure decreases dramatically, and the blood flow to the heart is significantly increased.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result? 1. Cystic fibrosis 2. Phenylketonuria 3. Down syndrome 4. Neural tube defect

4. Neural tube defect Rationale: Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

Which client is at increased risk for postpartum hemorrhage? 1. One who breast-feeds in the birthing room 2. One who receives a pudendal block for the birth 3. One whose third stage lasts less than 10 minutes 4. One who gives birth to an infant weighing 9 lb 8 oz

4. One who gives birth to an infant weighing 9 lb 8 oz (4366 g) Rationale: The risk for a postpartum hemorrhage is greater with large infants, because the uterine musculature has been stretched excessively, thus impairing the ability of the uterus to contract after the birth. Early breast-feeding stimulates uterine contractions and lessens the chance of hemorrhage. Having a pudendal block for the birth does not contribute to the risk for postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. A third stage of labor lasting less than 10 minutes is a short third stage; a prolonged third stage of labor, 30 minutes or longer, could increase the risk of postpartum hemorrhage.

Cramping and vaginal spotting occurring at 12 weeks' gestation in conjunction with a closed cervix is characteristic of which problem? 1. Missed abortion 2. Inevitable abortion 3. Incomplete abortion 4. Threatened abortion

4. Threatened abortion Rationale: Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion.

Which finding would indicate infection in a pregnant client? Select all that apply. 1. Chills 2. Fever 3. Diarrhea 4. Flank pain 5. Burning on urination

ANS: 1, 2, 3, 4, 5 Rationale: Findings indicative of infection include chills, fever, diarrhea, flank pain, and burning on urination. These findings would be reported to the health care provider for additional testing.

Which risk to the fetus is associated with a maternal diagnosis of chorioamnionitis? Select all that apply. 1. Sepsis 2. Bacteremia 3. Pneumonia 4. Cerebral palsy (CP) 5. Respiratory distress syndrome (RDS)

ANS: 1, 2, 3, 4, 5 Rationale: If a pregnant client is diagnosed with chorioamnionitis, risks to the fetus include sepsis, bacteremia, pneumonia, CP, and RDS.

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for which complications? Select all that apply. One, some, or all responses may be correct. 1. Seizures 2. Preterm labor 3. Multiple gestation 4. Chromosomal anomalies 5. Bleeding in the first trimester

ANS: 2, 3, 4, 5 Rationale: Increased risk for preterm labor is linked to age; it occurs more commonly in older primigravidas and adolescents. Mature women have an increased incidence of multiple gestations as a result of fertility medication use and in vitro fertilization. After 35 years of age, mature women have an increased risk of having children with chromosomal abnormalities. Bleeding in the first trimester as a result of spontaneous abortion is more common in mature gravidas. Seizures are not more common in mature gravidas.