Pregnancy, Labor, Childbirth, Postpartum - At Risk

The husband of a client in labor asks about an indentation on his wife's abdomen. The nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action?

Explaining to him what it means and notify the practitioner Rationale: Bandl's ring is a pathological retraction ring, a sign of impending uterine rupture. There is a ridge around the uterus at the junction of the upper and lower uterine segments. The upper segment is distended and thin and the lower segment is thick. Although the ring may occur during the second stage of labor, it is not a sign that the second stage of labor is beginning. A retraction ring impedes the progress of labor; it is associated with premature rupture of the membranes, dystocia, and prolonged labor. A retraction ring is pathological, not expected.

A nurse is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity?

Hypotonia Rationale: Hypotonia occurs with magnesium sulfate toxicity because of skeletal and smooth muscle relaxation. Pallor, tremor, and tachycardia are not signs of magnesium sulfate toxicity.

A client with type 1 diabetes is being counseled on what to expect during her recently confirmed pregnancy. Which statement indicates that the client needs further education?

"I can expect that my insulin requirements will be less." Rationale: Insulin requirements during pregnancy will increase during the second and third trimesters. The other options (lower insulin requirements, lower blood glucose readings in the third trimester, reducing the risk of urinary tract infection by drinking more water) are true statements that do not indicate a need for further education.

A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to avoid. Which nutrient is included on the list?

Amino acids Rationale: PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine, an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people with PKU.

A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in bed. What should the nurse do first?

Check the client's fundus for firmness. Rationale: After a spontaneous abortion the uterine fundus should be palpated for firmness, which indicates effective uterine tone. If the uterus is not firm or appears to be hypotonic, hemorrhage may occur; a soft or boggy uterus also may indicate retained placental tissue. The nurse would notify the health care provider if necessary after checking for fundal firmness. Administering the prescribed sedative is not the priority; the potential for hemorrhage must be monitored. Taking the client to the operating room is unnecessary; fetal and placental contents are small and expelled easily.

A client in labor, dilated 4 cm, is admitted to the birthing room. An electronic fetal monitor is applied. Which assessment should alert the nurse of the need to notify the practitioner?

Contractions every minute that last for 120 seconds Rationale: These contractions are too frequent and prolonged for a client who is dilated only 4 cm; she may become exhausted, which will compromise the fetus. Contractions every 4 minutes that last 50 seconds, fetal heart rate acceleration at the beginning of a contraction, and fetal heart rate deceleration to 110 beats/min before the peak of a contraction are all expected findings and do not need further intervention.

During the first prenatal visit of a woman who is at 23 weeks' gestation, the nurse discovers that she has a history of pica. What is the most appropriate nursing action?

Determining whether the diet is nutritionally adequate Rationale: The primary concern for a pregnant women who practices pica is that her diet is nutritionally inadequate. Nutritional guidance may be necessary, depending on the findings of this assessment. Pica does not indicate a psychologic/emotional disturbance; frequently it is influenced by the client's culture. If a substance is not toxic to the mother, it is generally not fetotoxic. Iron is routinely prescribed during pregnancy; this does not specifically address the practice of pica.

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

Gravida I who has had an intrauterine fetal death Rationale: Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and high birthweight are not risk factors for DIC.

A client's labor has progressed to the point where she is dilated 6 cm dilated, but the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time?

Inspecting the perineum Rationale: After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at this time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.

A nurse is assessing the perineum of a primipara who has had a right mediolateral episiotomy. What finding associated with this type of episiotomy will influence future focused nursing assessments?

More infections Rationale: There is a greater chance of infection with a mediolateral episiotomy than a midline episiotomy because more muscle fibers and major blood vessels are affected. In addition, this type of episiotomy is harder to repair, its healing is slower, and it is more painful for the mother than the midline episiotomy. There is more tissue damage with a mediolateral episiotomy than with a midline episiotomy, so there is more, not less, edema. More blood vessels are injured with a mediolateral episiotomy, so there is more bleeding and bruising than with a midline episiotomy. In a mediolateral episiotomy large muscles used in ambulation are cut, so there is more discomfort with movement than with a midline episiotomy.

A client at 38 weeks' gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity?

Patellar reflex Rationale: An absence of deep tendon reflexes is one of the first signs of magnesium sulfate toxicity. Magnesium sulfate interferes with the release of acetylcholine at the synapses, thereby decreasing neuromuscular irritability. Magnesium sulfate toxicity cannot be determined by alterations in the maternal heart rate or blood pressure. Diuresis and its related weight loss are signs of the therapeutic effect of magnesium sulfate.

A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing:

Sodium Rationale: If the client consumes more than the usual daily sodium intake, excess fluid retention results; this will increase the cardiac workload. Antacids that do not contain sodium do not cause fluid retention; it is best for this client to seek medical advice before taking an antacid.

A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. What action should the nurse take first?

Starting oxygen therapy Rationale: The client is hemorrhaging and has decreased cardiac output. Oxygen is needed to prevent further maternal and fetal compromise. Administering an opioid will sedate an already compromised fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Although blood should eventually be drawn for laboratory tests, it is not the priority.

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. What complication of severe preeclampsia requires diligent monitoring of the blood pressure?

Stroke Rationale: The likelihood of a stroke or brain attack increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations in blood pressure do not affect the status of clotting factors.

A nurse who is caring for a postpartum client is concerned because the woman is at risk for hemorrhage. Which factor in the client's history alerted the nurse to this concern?

Multifetal pregnancy Rationale: Overdistention of the uterus because of a large fetus, multiple gestation, or hydramnios predisposes a woman to uterine atony, which may cause postpartum hemorrhage. A short duration of labor may lead to a precipitous birth, which is potentially harmful to the fetus but does not affect uterine contractions after the birth. Previous cesarean birth is not related; unless uterine atony is present, hemorrhage should not occur. Age greater than 40 years is not a factor in involution of the uterus.

During an emergency birth the fetal head is crowning on the perineum. How should a nurse support the head as it is being born?

By distributing the fingers evenly around the head Rationale: Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.

Two hours after an uneventful labor and birth, a client's uterus is four fingerbreadths above the umbilicus. After urinary catheterization, the fundus remains firm and four fingerbreadths above the umbilicus. What is the priority nursing action?

Notifying the health care provider Rationale: The increased height of the uterus may result from accumulation of blood in the uterus from internal hemorrhage; vital signs may be indicative of impending shock. The client needs immediate therapeutic intervention; she may be having an intrauterine hemorrhage. Rechecking the vital signs, recatheterizing the client in a hour, and palpating the fundus may all be done at some point, but they are not the priority in the presence of a possible emergency.

A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response?

"A beta-adrenergic." Rationale: Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity, when birth is likely to occur within 24 to 48 hours.

A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn, and the nurse teaches her self-care measures. What statement indicates to the nurse that the client understands the teaching?

"I won't take antacids that contain sodium." Rationale: Excess fluid retention, which increases the workload of the heart, is an undesirable effect of sodium intake, especially for an individual with heart disease. Lying down for 1 hour after eating will exacerbate heartburn because it promotes gastric regurgitation. Fluid intake should be approximately 2 L a day. Three large meals a day will distend the stomach, which could result in heartburn. Small frequent meals, spaced throughout the day, are preferred.

A nurse on the postpartum unit is assessing several clients. Which clinical finding requires immediate investigation?

A slow trickle of blood from the vagina Rationale: Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm.

A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. What precaution should the nurse initiate?

Padding the side rails on the bed Rationale: Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. Although some clients experience an aura before a seizure, there is not enough time to use a call button and wait for help. Oxygen is useless during a seizure when the client is not breathing or is thrashing about. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.

After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify?

Taking-in Rationale: By discussing the experience, the client is bringing it into reality; this is characteristic of the taking-in phase. The client is not ready to assume the tasks of the letting-go phase until completing the tasks of the taking-in and taking-hold phases. The taking-hold phase is marked by an increased desire to resume independence; this statement reveals that the client is not ready for this phase. The working-through phase is not a separate phase of adjustment to parenthood; it is not relevant.

A nurse is caring for a client whose contraction stress test result (CST) is positive. The nurse remains with the client and continues to assess the fetal and maternal monitor strips. What complication does the nurse anticipate?

Uteroplacental insufficiency Rationale: A positive CST result is indicative of a compromised fetus; late decelerations during contractions are associated with uteroplacental insufficiency. Preeclampsia does not cause a positive CST result. A CST is contraindicated for a client with a suspected placenta previa because the contractions may cause bleeding. A CST is contraindicated for a client with a suspected preterm birth or a gestation less than 33 weeks' duration because the contractions may induce true labor.

A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform these interventions?

1.Call for help. 2.Check fetal heart tones. 3.Increase the maintenance IV infusion rate. 4.Start oxygen at 8 L/mask. 5.Call the health care provider. Rationale: Calling for help will allow all other actions to be completed more quickly. This is especially critical during an emergency situation. Next the nurse should assess the fetal heart tones to identify the effect of the bleeding on the fetus, because the fetus often shows signs of distress before the mother does. After checking the fetal heart tone the nurse should increase the IV infusion rate, which should take only seconds and can have a significant effect on circulation. Oxygen can be instituted after the IV infusion rate has been increased; this will be of benefit to both mother and fetus. Calling the primary health care provider is important, but instituting lifesaving measures takes precedence.

One week after a teenage girl gives birth, the public health nurse makes a home visit. Which statement made by a family member in the home indicates a need for nursing intervention?

The infant's grandmother states, "I take care of the baby so my daughter can devote her time to finishing school." Rationale: It is essential for the parent to bond with the newborn, and this requires spending significant time with the infant to learn newborn behavioral cues; when a grandparent assumes the role of infant caregiver, bonding may be inadequate and role confusion may result. Although the absence of the infant's father is a concern, the nurse does not intervene in personal relationship issues. The addition of a newborn to a family unit will naturally require adjustments, so this observation is not a concern unless problems are identified. The provision of financial support is beneficial because it gives a sense of security and decreases stress.

A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur?

6th Rationale: In the sixth week the fallopian tube can no longer expand to accommodate the size of the growing embryo. A tubal pregnancy cannot advance to the 12th, 16th, or 18th week because the tube cannot expand to accommodate the growing fetus.

While gently performing Leopold maneuvers on a client with suspected placenta previa, what clinical finding does the nurse anticipate?

A high, floating presenting part Rationale: With a low-implanted placenta (placenta previa), the presenting part may be impeded from entering the pelvis. A hard, rigid uterus occurs with abruptio placentae. Engagement is difficult with a low-lying placenta. Placenta previa does not make it difficult to palpate small fetal parts.

A laboring client reports low back pain. What should a nurse recommend to the client's coach that will promote comfort?

Apply pressure to her back during contractions. Rationale: The application of back pressure combined with frequent position changes will help alleviate the discomfort. Although flexing the knees may be comfortable for some individuals, rubbing the back and alternating positions are usually more effective. The supine position places increased pressure on the back and often aggravates the pain. Neuromuscular control exercises are used to teach selective relaxation in childbirth classes; they will not relieve back pain during labor.

A nurse is caring for a postpartum client who had abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring?

Bleeding at the venipuncture site Rationale: Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.

The nurse in the prenatal clinic is providing nutritional counseling for a pregnant woman with a cardiac problem. What should the nurse advise the client to do?

Control the number of calories consumed. Rationale: Controlling caloric intake is recommended to keep weight gain to no more than 25 lb so the increased cardiac workload that occurs during pregnancy may be controlled as much as possible. Fats are not specifically limited; however, they should be eaten in moderation to control the total number of calories consumed. Increased sodium and moderate protein are not advised for clients with cardiac problems.

An infusion of oxytocin is administered to a client for induction of labor. After several minutes the uterine monitor indicates contractions lasting 100 seconds with a frequency of 130 seconds. What is the next nursing action?

Discontinuing the infusion Rationale: Contractions lasting too long and occurring too frequently can lead to fetal hypoxia; stopping the oxytocin infusion should stop the contractions, thereby increasing oxygen flow to the fetus. The fetal heart rate should be monitored, but this is not the priority. Oxytocin (Pitocin) will continue to promote uterine contractions; this is unsafe because the prolonged, frequent contractions decrease oxygen flow to the fetus. Turning the client on her left side will promote placental perfusion, but it is not the priority at this time.

A nurse in the high-risk prenatal unit admits a client at 35 weeks' gestation with a diagnosis of complete placenta previa. What is the most appropriate nursing intervention at this time?

Having oxygen available at the bedside Rationale: If hemorrhage should occur, oxygen is needed to prevent maternal and fetal compromise. A perineal pad is not necessary; close monitoring is required.The client admitted with a complete placenta previa is usually on complete bed rest. It is too soon to discuss the neonatal intensive care unit, and this may be unnecessary anyway.

While a multiparous client is in active labor her membranes rupture spontaneously, and the nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action?

Holding the presenting part away from the cord Rationale: Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.

The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous therapy the nurse notes blood continually oozing from the puncture site. What is the nurse's next action?

Informing the health care provider of this finding Rationale: Oozing from a venipuncture site is a sign that disseminated intravascular coagulopathy (DIC) is developing. This pathologic form of clotting causes widespread bleeding and clotting. It is never a primary diagnosis; it always results from some problem that has triggered the clotting cascade. The health care provider must be informed because this diagnosis may change the client's plan of care. There is no information indicating the need for a different IV site. Also, subsequent venipunctures must be proximal and not distal to previous sites. Delivery will likely be managed initially with Pitocin; however, this is not the first action to be taken in regard to an oozing IV site. Generally oxygen is started for signs of hypoxia, fetal or maternal; because there is no fetal indication for oxygen and no information in the stem indicating maternal hypoxia, application of oxygen is not the next intervention.

What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia?

Maintaining a quiet, darkened environment Rationale: A quiet, darkened room reduces stimuli, which is essential for limiting or preventing seizures. IV infusions are not limited. Infusions are monitored closely and usually maintained at a volume of 125 mL/hr. Precipitous birth is not a usual side effect of magnesium therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be kept on hand in case signs of toxicity appear.

A client with heart disease is admitted to the birthing suite. How can the nurse try to prevent the development of cardiac decompensation during her labor?

Positioning her on the side with her shoulders elevated Rationale: The side-lying position, particularly the left, takes the weight off large blood vessels, increasing blood flow to the heart; elevating the shoulders relieves pressure on the diaphragm. The client's head is too low in this position if she is only positioned with her head on a pillow; it should be elevated above the shoulders. Sodium leads to increased fluid retention; it is contraindicated in a client with heart disease; if it is prescribed, the nurse should question the health care provider. Administering the prescribed intravenous piggyback infusion of oxytocin is contraindicated unless some uterine inertia occurs; if it is prescribed, the nurse should question the health care provider.

A nurse is teaching a client with preeclampsia about improving her health. What is the most therapeutic instruction for the nurse to give the client?

Rest often in the side-lying position. Rationale: Rest is advised to reduce arteriolar spasm, and the side-lying position promotes more efficient venous return to the heart; this improves cardiac output and placental perfusion. Sodium is necessary to maintain circulatory volume and should not be restricted in the diet. Excessive walking is contraindicated; too much walking may increase general arteriolar spasm. Fluid restriction is contraindicated, and, because of the increased circulatory volume during pregnancy, the client needs 2000 mL of fluid per day.