Chapter 11: Assisted Delivery and Cesarean Birth

A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. Which of the following would be your best response?

"Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth." Low cervical incisions allow for vaginal birth following cesarean birth because they do not involve the fundal portion of the uterus.

How should the nurse counsel a patient who has arrived for a scheduled repeat cesarean delivery?

"An IV catheter will be placed, and we will do some preoperative blood work. Then we will give you some antibiotics." Epidural or spinal anesthesia is most commonly used for a scheduled cesarean, and the woman is awake during the procedure. Immediately after the procedure, the woman is transferred to the post anesthesia care unit or the recovery unit to recover from the surgery for 1 to 2 hours. The Foley usually remains in place for 24 hours.

A nurse has learned about methods newer than the Bishop score to determine if a cervix is favorable for induction. The method that measures cervical length uses which of the following measurements to determine a favorable induction?

27 mm or less A new method for predicting labor readiness is determination of cervical length by endovaginal ultrasound. A cervix that measures 27 mm or less is associated with a favorable induction rate.

The maternal health nurse is caring for multiple women who wish to attempt a vaginal birth after cesarean (VBAC). Which client will not be able to attempt a VBAC due to contraindications?

28-year-old with a placenta previa Placenta previa is a contraindication for VBAC. Two previous cesarean sections, gestational diabetes, and Rh-negative blood do not represent contraindications for VBAC.

According to the National Vital Statistics System (NVSS), what was the national cesarean rate in 2014?

32% The national cesarean rate in 2014 was 32.2%.

Mrs. Atkins is 40 weeks' pregnant by ultrasound, and the induction of labor is being discussed by Mrs. Atkins and her birth attendant. The birth attendant tells Mrs. Atkins, "I am going to do a pelvic exam so that I can assess your readiness for labor. I will obtain what is known as a Bishop Score, and it will tell me how ready you are to go into labor." What Bishop Score would indicate a favorable response to oxytocin-induced labor?

8 or above In general, a score of 8 or greater is associated with a favorable response to oxytocin-induced labor; that is, the cervix is soft, in an anterior position, partially dilated and effaced, with an engaged fetus.

Which woman is most likely to have a successful VBAC (vaginal birth after cesarean)?

A 32-year-old who has had 1 previous cesarean delivery, has gone into labor spontaneously, and then has been augmented with AROM Women who are most likely to have a successful VBAC are those who have had only 1 previous cesarean, are younger than 40, and go into labor spontaneously.

The nurse is caring for a patient recovering from a cesarean birth. Which assessment should the nurse make a priority for this patient?

Abdominal texture After a cesarean birth, the nurse should assess the abdomen for softness. A hard, "guarded" abdomen is one of the first signs of peritonitis, a complication that may occur with any abdominal surgical procedure. Although important, breast filling does not lead to a life-threatening complication. Plans to breastfeed could have been determined prior to the cesarean birth. Because the baby was delivered through the abdomen, the perineum should not be edematous.

The maternal health nurse is caring for a woman who had an uncomplicated cesarean birth four hours ago. The client tells the nurse, "I feel so bloated and have a pinching pain in my shoulder." What is the nurse's priority action?

Ambulate the client The client is describing gas pain, a common postoperative complaint associated with cesarean section delivery. The priority action of the nurse is to ambulate the client in order to relieve the client from the retained gastrointestinal gas. Auscultating the client's lungs or repositioning the client will not relieve the client of this pain and are not the priority actions. It is not necessary for the nurse to notify the health care provider of the client's pain, as this is a commonly reported discomfort that is typically relieved with ambulation as tolerated.

A nurse is providing a client with preoperative teaching regarding cesarean birth. Which of the following interventions should she recommend as the most effective means of preventing lower-extremity circulatory stasis?

Ambulation The most effective way to stimulate lower-extremity circulation after a cesarean birth is by early ambulation. An incentive spirometer is used to encourage deep breathing, which in turn helps fully aerate the lungs and prevent stasis of lung mucus. Turning postoperatively is important to prevent both respiratory and circulatory stasis, but is not as effective as ambulation for stimulating lower-extremity circulation.

What is the most effective way to stimulate circulation after cesarean birth?

Ambulation within 4 hours of birth Early ambulation is extremely important to prevent edema and DVT formation. Women should be encouraged to ambulate 4 hours after cesarean birth. Venodyne boots and TEDS stockings are helpful, but ambulation is the best way to stimulate circulation.

A woman whose fetus at 30 weeks of pregnancy is failing to thrive in utero is told her physician wants to deliver the baby by cesarean birth today. She asks the nurse why this would be preferred to a vaginal birth. Which of the following would be your best response?

"Cesarean birth will reduce pressure on the immature head." Cesarean birth reduces pressure on the fetal head because the head does not participate in cervical dilation.

A client underwent a cesarean birth due to fetal distress. The medical records reflect a low transverse uterine incision was used. When speaking with the nurse the client questions her ability to give birth vaginally with her next pregnancy. What response by the nurse is most appropriate?

"Having a cesarean birth does not mean you will have a cesarean birth with future births." There are a variety of reasons for an unscheduled cesarean birth. The reason in this case was a prolonged labor. The ability to experience a vaginal birth after a cesarean (VBAC) will be tied closely to the reasons for the cesarean birth. The woman who has a cesarean birth due to a prolonged labor experience may be a candidate for a VBAC. The incision used for this client does not prevent a future VBAC.

The maternal health RN is caring for a client in active labor with a history of a previous cesarean section delivery. Which statement(s) made by the client would make the nurse suspect the client is experiencing a uterine rupture? Select all that apply.

"My chest hurts." "I just felt a popping sensation in my abdomen." "My abdomen is rock hard." Uterine rupture is a medical emergency and the nurse must be able to recognize signs and symptoms of the condition. Reports from the woman feeling a "popping" sensation in the abdomen, severe referred pain (such as the chest), or severe contractions that do not end are symptoms of uterine rupture. The remaining statements do not reflect the signs and symptoms of uterine rupture.

The nurse is instructing a primipara who has concerns about the need for a cesarean section due to her sister's obstetrical history. Which statement by the client needs further instruction?

"My sister had a cesarean section with the first and then needs it for all subsequent pregnancies." Cesarean sections are used most often as a prophylactic measure to alleviate problems of birth such as cephalopelvic disproportion, breech or multiple fetus births, or failure to progress in labor. A common misconception is that once a woman has a cesarean section, all of births must be delivered in that manner. Actually, vaginal births after a cesarean section are common depending upon location of the incision.

A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births?

"Not if you fulfill the criteria for vaginal birth after cesarean." To fulfill the 2020 National Health Goals regarding cesarean births and answer the patient's question, the nurse should respond that patients who fulfill the criteria for vaginal birth after cesarean should attempt a vaginal birth with subsequent children. All future births do not need to be done through cesarean. The patient has a voice with deciding the type of birth that she would prefer with each pregnancy. Most women do not prefer cesarean births. This type of birth might not take as long; however, it is a painful surgical procedure.

A woman's physician has suggested that she use patient-controlled analgesia for pain relief after a cesarean birth. She asks the nurse if this will be effective. Which of the following would be the nurse's best response?

"Not only will it be effective, but it also will reduce the amount of narcotic needed." Patient-controlled analgesia is well documented as an effective pain-relief measure following cesarean birth.

The nurse is preparing a client who has arrived for her scheduled cesarean delivery. Which actions should the nurse prioritize?

Ask the woman when she last ate or drank, clip the hair from her abdomen and perineal area, and insert an 18-gauge IV catheter The surgeon must obtain informed consent. Administration of morphine is not always included in a preoperative cesarean delivery protocol. The incision site, not the preoperative area, is cleansed by surgeons in the operating room. Clippers are preferred over razors. A 20-gauge or larger bore catheter is used for IV infusion during a cesarean delivery to provide a ready access if blood products become necessary to administer.

A woman has just entered the recovery room after cesarean birth of a baby weighing 9 lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her HR is 120 and BP is 80/40. What nursing action should be a priority?

Assess for bleeding The elevated HR and BP could be an indication of hemorrhaging. The priority will be to assess for bleeding by assessing the uterine fundus and checking the perineum. Although this is a responsibility of the RN, the LPN should also be aware. The other choices may follow if deemed necessary, depending on the cause of the elevated HR and BP.

A 35-year-old P1001 has been admitted for a scheduled repeat cesarean. As the nurse prepares the patient for surgery, what is the best way to begin preoperative teaching?

Assess how much the woman already knows about cesarean. It is best for the nurse to assess the situation before beginning postoperative teaching. This patient may already have a lot of knowledge because she has had a previous cesarean. It is not necessary to wait for the physician and the anesthesiologist to complete the history. Focusing on the risks may contribute to fear and anxiety. Teaching can often help to alleviate fear.

The maternal health nurse assists the birth attendant in a forceps-assisted birth. After the birth of the infant, what is the nurse's priority?

Assess the infant for trauma A forceps-assisted birth may cause trauma to the infant and the nurse's priority is to assess the infant for signs of trauma. Assessing the mother for bleeding is important; however, the birth attendant assesses for bleeding immediately after birth while the nurse is assessing the newborn. The mother may or may not require supplemental oxygen and this action is not the priority. Pitocin is typically increased immediately after birth to promote uterine involution; however, this is not the priority action.

A 21-year-old has been in labor for 4 hours; her examination 2 hours ago revealed 6 cm/100%/-3. During a contraction, she spontaneously ruptures her membranes. The doctor checks the patient, finds her to be 9 cm/100%/-3, and states that the cord is palpable. What should the nurse do?

Call for help and prepare the patient for an emergency cesarean delivery. When the cord is palpable on examination, this indicates that the cord has prolapsed and emergency cesarean delivery is needed. This patient is not a candidate for vacuum or forceps delivery because she is not 10 cm dilated.

The nurse is caring for a client who is presenting for the first prenatal visit. Which finding(s) should prompt the nurse to anticipate a cesarean birth? Select all that apply.

Cephalopelvic disproportion Failure to progress in labor Multiple fetal births Cesarean birth is a procedure used most often as a prophylactic measure to alleviate problems of birth such as cephalopelvic disproportion, multiple fetal births, and failure to progress in labor. Aversion to prolonged labor may influence a client's preference to undergo cesarean birth, but is not a finding that should cause the nurse to anticipate the procedure. Previous cesarean births do not exclude the possibility of vaginal birth.

The nurse is caring for a client who is receiving epidural analgesia with morphine following cesarean birth. For which side effects should the nurse monitor? Select all that apply.

Itching Nausea Vomiting Intense itching, nausea, and vomiting can occur following epidural morphine administration. These side effects can be managed with antihistamines for itching and antiemetics for nausea. Hyperventilation and gastrointestinal bleeding are not expected side effects of epidural morphine administration.

A woman is scheduled to have epidural anesthesia for a cesarean birth. Which of the following would the nurse anticipate including in the preoperative plan of care while she waits for the anesthetic?

Keeping her turned on her side A side-lying position both helps prevent hypotension syndrome and positions her for anesthetic administration.

The nurse is teaching a prenatal class about a cesarean delivery. What benefit of a low transverse uterine incision should the nurse point out in the teaching?

Least likely to rupture during subsequent labors. A low transverse uterine incision is less likely to rupture, enabling the woman the opportunity of a VBAC with subsequent pregnancies. A classical incision is used when the baby needs to be delivered urgently and quickly. It is also easier to extend the incision in the uterus if the surgeon is having difficulty getting the fetus out. A premature fetus which needs to be delivered will probably be an emergent case and require the horizontal incision to get to the infant quickly.

To prevent tearing of the perineum of a client during birth, a physician performs a mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral episiotomy over a midline episiotomy is which of the following?

Lower risk for rectal mucosal tear Mediolateral incisions have the advantage over midline cuts in that, if tearing occurs beyond the incision, the tear will not be directed toward the rectum, creating less danger of a rectal mucosal tear, which can result in loss of sphincter function and fecal incontinence later in life. Midline episiotomies, however, heal more easily, cause less blood loss, and result in less postpartal discomfort.

A woman is being seen in the clinic for care during her first pregnancy and birth. The nurse will educate this woman and her significant other about their planned cesarean delivery and what can be expected. When should the nurse provide this family education?

Each time the nurse sees the woman before surgery The focus of nursing intervention for a planned cesarean is family education. Each time you encounter the woman before surgery is an opportunity to explore with the woman and her partner what they know about cesarean delivery. Part of the education will include the circulatory and musculoskeletal activities which the woman can practice before the surgery to help prevent potential complications after the surgery. The nurse should also assess how much the family know and ensure they have the correct information.

To prevent thrombophlebitis following a cesarean birth, which of the following would be most important to implement?

Encourage the woman to ambulate. Ambulation increases circulatory function, helping decrease blood clotting.

The nurse is caring for a 45-year-old client who will undergo cesarean birth. Which age-related finding should the nurse treat to reduce the client's surgical risk?

Gestational diabetes Gestational diabetes is a condition associated with age for which the nurse should anticipate treatment to reduce the client's surgical risk. Venous stasis, poor nutritional status, and obesity may all affect the surgical outcome, but may occur regardless of age.

A husband asks if he can view his wife's cesarean birth. Which of the following reflects a modern policy on this subject?

He can view it if he chooses, especially because his wife will be awake. Childbirth should be a shared experience to the maximum extent possible.

The nursing instructor is teaching about cesarean birth and informs the students that the main reasons for this procedure include which of the following? Select all that apply.

History of previous cesarean birth Fetal malpresentation Non-reassuring fetal status Labor dystocia The four main reasons for cesarean birth include history of previous cesarean birth, labor dystocia, non-reassuring fetal status, and fetal malpresentation. Fast labor is not a reason for cesarean birth.

A woman is about to go for her first cesarean delivery and asks the nurse what complications can come from this type of delivery. The nurse correctly identifies which of the following as the number one complication of cesarean delivery?

Infection Infection is the most common complication of cesarean delivery. However, any of the responses can occur.

The nursing instructor is conducting a class presenting the various aspects of a cesarean delivery. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication?

Infection Infection is the most common postoperative complication. Laceration of the uterine artery is an intraoperative complication. Pneumonia and thrombosis are also potential postoperative complications but not as common as infection.

A patient who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the patient's fluid status during the procedure?

Initial intravenous fluid therapy. A patient who enters surgery with a lower than usual blood volume will experience the effect of surgical blood loss more than a patient who has a normal blood volume. A patient who has had a long labor before a cesarean birth is scheduled may fall into this category, because the patient may have had little to eat or drink for almost 24 hours. Intravenous fluid replacement needs to be initiated preoperatively and continued postoperatively to prevent a serious fluid or electrolyte imbalance. Since surgery is imminent, the patient should be kept at "nothing by mouth" status, which means no ice chips or clear liquids. An antiemetic is not indicated for the patient at this time.

The nurse is concerned that a pregnant patient will have a complication from a medication after a cesarean birth. For which prescribed medications are complications most likely to occur? Select all that apply.

Insulin Anticoagulant Antihypertensive Antianxiety agent Some medications can cause complications with cesarean births. Insulin may lead to hypoglycemia during labor or hyperglycemia if a dextrose solution is provided. Anticoagulants may cause hemorrhage due to lack of hemostasis during surgery. Antihypertensives may result in hypotension after anesthesia. Antianxiety agents may cause hypotension after anesthesia. There is no evidence to suggest that beta2-adrenergic blockers will cause a complication after a cesarean birth.

A nurse is preparing to teach a client about her potential cesarean delivery and explains the possible incisional locations. Which information should the nurse include when pointing out the most common type of incision is the low transverse method?

Minimizes blood loss. The lower segment is the thinnest portion of the uterus with the least vascular activity, and an incision at this site minimizes blood loss. Facilitating rapid access to the fetus, extensive adhesions involving the bladder, and need for immediate maternal hysterectomy are reasons for a vertical incision directly into the wall of the uterine body to be chosen, and not for a transverse incision. The vertical incision is often chosen in emergency cases, where the low transverse is most often used in planned cesarean deliveries.

The nurse is caring for a postoperative client who is recovering from a cesarean birth. Which client concern(s) should be addressed in her plan of care? Select all that apply.

Pain related to a surgical incision Deficient fluid volume related to blood loss from surgery Risk for infection related to a surgical incision Risk for impaired parent-infant attachment related to unplanned method of birth The client's plan of care should address the pain related to a surgical incision, deficient fluid volume related to blood loss from surgery, risk for infection related to a surgical incision, and risk for impaired parent-infant attachment related to unplanned method of birth. Fear related to impending surgery would be relevant to a preoperative client about to undergo a cesarean birth.

The nurse is coordinating upcoming procedures and appointments for a client about to undergo a cesarean birth. Which specialist(s) should the nurse anticipate in the client's care? Select all that apply.

Pediatrician Anesthesiologist Surgeon Recovery room personnel Coordinating health care team members such as an anesthesiologist, surgeon, pediatrician, and recovery room personnel is an important intervention for ensuring continuity of care for the client. A referral to a nutritionist should not be anticipated in the absence of other complicating circumstances.

The nurse has received the beginning-of-shift report for five clients. With which conditions will the nurse anticipate a cesarean delivery? Select all that apply.

Placenta previa Active vaginal or cervical herpes lesions A classical uterine scar Active herpetic lesions on the perineum, invasive cervical cancer, a previous classical incision on the uterus, and complete placenta previa are all contraindications to a vaginal delivery. A woman who has had a previous cesarean section or a low-lying placenta may be counseled about the risks and benefits of a trial of labor after cesarean and subsequent vaginal delivery. Breast cancer would not be an indication of needing a cesarean delivery.

Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes?

Postpartum hemorrhage During cesarean birth, the surgeon thoroughly cleans inside the uterus. Therefore, lochia is less than after a vaginal delivery. If lochia flow is moderate or heavy, it could indicate a postpartum hemorrhage.

A primigravida whose baby is presenting breech is scheduled to have a cesarean birth. Which of the following would you prepare her for postoperatively?

Presence of an indwelling catheter Because the bladder is handled during surgery, it may not empty well following surgery, necessitating an indwelling catheter.

The nurse is caring for a client who has developed a paralytic ileus following a cesarean birth. Which element of the procedure results in this condition?

Pressure on the intestine Pressure on the intestine during cesarean birth may result in a paralytic ileus or halting of intestinal function with obstruction. The intestine is not handled, displaced, or incised during a cesarean birth.

The nurse is caring for a client in labor who is now being advised to have a cesarean delivery. What group of reasons are most common for the need of a cesarean delivery?

Previous cesarean, labor dystocia, nonreassuring fetal status, and fetal malpresentation Previous cesarean, labor dystocia, nonreassuring fetal status, and fetal malpresentation are the MOST common reasons for cesarean delivery. The LEAST common reasons for cesarean delivery include placenta previa, abruptio placentae, cephalopelvic disproportion, active vaginal herpes lesions, prolapse of the umbilical cord, ruptured uterus, and certain medical and obstetric conditions.

The nurse is implementing the plan of care for a client who underwent an unexpected cesarean section. How should the nurse proceed with providing education to the client?

Provide discharge instructions early in the client's care The nurse should provide discharge instructions early in the client's care, as the typical length of stay in the hospital after a cesarean birth is 1 to 2 days. It is not appropriate to delay instruction to allow time for the client and infant to bond, as education may be necessary to support the client and infant's bond. While it may be helpful for the client for a support person to be present, it is not necessary to request that all immediate family members be present prior to providing instruction. Reserving a family conference room should not be necessary in the absence of other complicating circumstances, and this type of space may have limited availability depending on the institution.

The nurse is assessing a neonate after a cesarean delivery. Which most common complication should the nurse be prepared for?

Respiratory distress The most common fetal complications involve miscalculation of dates, which leads to the unintended delivery of a premature fetus and respiratory distress due to retained fluid in the lungs. Hemorrhage and infection are the two most common maternal complications. A cone shaped head and facial nerve injury is seen in fetus' delivered via a vaginal delivery. Shoulder dystocia occurs during vaginal deliveries and is an obstetric emergency.

A woman has just been informed that she needs to have a cesarean delivery due to cephalopelvic disproportion. The patient asks the nurse if there is any danger for the baby if delivered by cesarean. The nurse correctly identifies which of the following as potential fetal complications of cesarean delivery? Select all that apply.

Respiratory distress Delivery of an immature fetus Laceration of the fetus Bruising All of the above are potential fetal complications of cesarean deliveries excepting increased respiratory drive due to anesthesia. Respiration is decreased.

A student observing in labor and delivery watches a physician introduce a hard plastic instrument with a hook on the end into the vagina during a digital examination. The physician proceeds to guide the hook to snag a hole into the membranes. This process causes the body to release prostaglandins, which induces labor and is known as which of the following?

artificial rupture of membranes Artificial rupture of membranes to induce labor introduces a hard plastic instrument with a hook on the end into the vagina during a digital examination. The practitioner then guides the hook through the cervix and uses the hook to snag a hole in the membranes. Although the others listed are use to "ripen" the cervix, they use different methods to do this.

A new mother calls the clinic on her fourth day after delivery and reports difficulty urinating and defecating because of the perineal pain. What does the nurse suspect is causing these problems?

episiotomy An episiotomy is an incision done right before birth. It requires repair with sutures that are absorbable and do not need to be removed. The pain of an episiotomy can cause vaginal pain when urinating and defecating. Having a cesarean or vaginal birth should not cause this type of pain. An infection may cause pain in the vagina, but normally it is not the cause of pain while urinating and defecating.

A client is being admitted at 41-weeks gestation with a cervix which is not ready for labor and delivery. Which procedure might the nurse prepare the client for? (Select all that apply.)

membrane stripping mechanical dilation locally applied prostaglandins artificial rupture of membranes If the cervix is not ready and a medical reason exists for labor induction, the nurse can expect one of the following methods to be used: membrane stripping, mechanical dilation, locally applied prostaglandins, artificial rupture of membranes, or oxytocin induction. An episiotomy is a surgical incision made into the perineum to enlarge the vaginal opening just before the baby is born.

A nursing student correctly identifies that an episiotomy that extends straight down into the true perineum is which of the following?

midline episiotomy There are two basic types of episiotomy. A midline episiotomy extends straight down to the true perineum, while a mediolateral episiotomy angles to the right or left of the perineum. The others are not types of episiotomies.

A nursing student asks the instructor if there are any reasons not to do an elective induction. The instructor correctly identifies which reasons? Select all that apply.

need for more interventions longer labor higher costs possible cesarean section An elective induction should never be done unless the woman understands that it often results in more interventions, longer labors, higher costs, and possible cesarean births. Shorter stays are not negative or a concern for elective inductions.

A nursing student correctly identifies which of the following as medical reasons to induce labor? Select all that apply.

postdate pregnancy pregnancy that persists beyond the due date premature rupture of membranes without spontaneous labor preeclampsia Some situations that warrant a medically induced induction are postdate pregnancy, pregnancy that persists beyond the due date, premature rupture of membranes without the onset of spontaneous labor, infection of fetal membranes, and preeclampsia. Gestational hypotension is not a reason.

A nurse is preparing a prenatal class for a group of couples who are in their third trimester. When explaining methods which can be used to help decrease the need for an episiotomy, which methods should the nurse prioritize? (Select all that apply.)

prenatal perineal massage using natural pushing techniques patience with the delivery process protecting the perineum immediately before birth Methods to minimize the need for episiotomy include prenatal perineal massage, using natural pushing techniques, patience with the delivery process, warm compresses to the perineum during second stage of labor, delivering the fetal head between contractions, and protection of the perineum immediately before birth. Speeding up the delivery does not minimize the risk for an episiotomy.

While the nurse is assessing the prenatal client's understanding of the information provided at a recent appointment, the client states, "I want to avoid the pain and long hours of labor, so I'm electing to have a cesarean birth." How should the nurse respond?

"A cesarean birth is a method to be used when vaginal birth is not possible—it is not a true option." It is important for the nurse to explain that a cesarean birth is a method to be used when vaginal birth is not possible, and is not a true option. For this reason, the nurse will not inform the health care provider of the client's decision to plan for a cesarean birth, although additional follow up with the client's health care provider may be required. Cesarean birth is one of the safest types of surgeries, but the nurse should not present a cesarean birth as an ideal option in the absence of other supporting information. It is not the responsibility of the client to make the decision to undergo a cesarean birth to avoid the risk of anoxia.

When counseling a patient about maternal risks and benefits of cesarean delivery, which of the following would not apply?

"A surgical incision may be made at the perineum to enlarge the vagina just before delivery of the baby." A surgical incision made at the perineum is an episiotomy and is not part of a cesarean delivery.

The maternal health nurse is preparing a pregnant client for a scheduled cesarean birth. After the informed consent has been signed and the health care provider has left the room, the client tells the nurse, "I am not sure I want to go through with this." What is the nurse's best response?

"Let's have a conversation with your doctor." It is important for the nurse to recognize when a client requires more information regarding an upcoming procedure, regardless of whether or not the client has signed an informed consent form. The nurse should reassure the client that the nurse will contact the health care provider and that the client can have a conversation with the health care provider. Asking the client, "Why are you scared?" and "What do you need to know about the procedure?" may make the client feel pressured and uncomfortable. Although telling the client that he or she has options, it is best to let the health care provider know that the client has concerns so that the health care provider may be the one discussing the various options for the client.

A woman with a history of a previous cesarean has signed the consent form for a VBAC. After dilating to 7 cm and making satisfactory progress in labor, she tells her nurse that she has changed her mind and wants a cesarean. What is the best response by the nurse?

"Since you no longer consent to a VBAC, I will let the physician know, and we'll begin preparing you for a cesarean delivery." The woman may verbally withdraw her consent at any time during the course of labor. At the time she withdraws her consent, the trial of labor is discontinued, and the woman is prepared for a cesarean delivery. This decision is not contingent on the physician's permission. The nurse should also not argue or try to change the client's mind.

A woman has just arrived to the recovery room after an emergency cesarean delivery and is anxious to begin breast-feeding her baby. What is the best response from the nurse?

"Sure, let me help you with that." Once out of the operating room, a woman who has given birth by cesarean can breastfeed just as if she had given birth vaginally.

The maternal health nurse is caring for a laboring client who has required a midline episiotomy due to infant shoulder dystocia. Which postpartum teaching will the nurse need to include related to the client's episiotomy? Select all that apply.

"The sutures are absorbable and do not need to be removed." "An ice pack may help decrease the pain." An episiotomy is a surgical incision made into the perineum to enlarge the vaginal opening just before the baby is born. Teaching for the client who has had an episiotomy includes notifying the client that the sutures are absorbable and do not need to be removed. Additionally, a sterile ice pack may be applied to help decrease the pain. The client does not need to avoid sitting directly on the toilet and should not apply a topical antibiotic cream to the incision.

Which of the following women most likely will not be a candidate to attempt a vaginal birth after having had a previous cesarean section?

A woman who had a cesarean section because of cephalopelvic disproportion The shape and size of the pelvis of a woman does not change with subsequent pregnancies. If a woman is unable to give birth vaginally because of cephalopelvic disproportion, she most likely will experience the same complication during future pregnancies.

A nursing student is asking the instructor how to assess whether a cervix is ready and favorable for labor induction. The nurse informs the student that a score is used known as which of the following?

Bishop score The Bishop score is used to determine whether a cervix is favorable and ready for induction. The Braden and Norton scales are used to predict pressure sore risk. The Apgar score is done immediately after birth to determine how well the baby tolerated the birth.

The maternal health nurse is caring for a woman who is in the immediate postoperative period after cesarean birth using a low transverse incision. When assessing the client, which potential complication will the nurse prioritize?

Bleeding Bleeding is an immediate life-threatening complication and takes priority. Infection, pain, and immobility are all important to assess; however, these do not take priority over the assessment of potential bleeding.

The nurse is caring for a group of clients on the birthing unit. For which client(s) should the nurse anticipate an emergency cesarean birth? Select all that apply.

Client with bright red, painless vaginal bleeding Client with a fetus exhibiting variable decelerations Client with abnormal amniotic fluid volume Client with three contractions in 20 minutes, lasting 35 seconds each, in active phase of labor The client with bright red, painless vaginal bleeding (a sign of placenta previa), the client whose fetus is exhibiting variable decelerations (a sign of premature placental separation), the client with abnormal amniotic fluid volume (a sign of fetal distress), and the client with three contractions in 20 minutes lasting 35 seconds each in active phase of labor (a sign of failure to progress) all may require emergency cesarean birth. The nurse should not anticipate a cesarean birth for a client whose pain is not adequately controlled by epidural analgesia.

The nurse is caring for client at risk for requiring a cesarean birth. What action by the nurse may reduce this risk?

Continuous support by a health care provider A dedicated, concerned health care provider such as a nurse decreases the incidence of cesarean births, which may decrease the likelihood that the client will require this procedure. While human papillomavirus education, fetal heart rate monitoring, and administering treatment for placenta previa may all be required, these do not reduce the likelihood that the client will require a cesarean birth.

After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?

Fear related to impending surgery The patient's emotional response after learning about a cesarean birth is most likely fear. The nurse should use the diagnosis of "fear related to impending surgery" to guide interventions at this time. The patient's emotional response is not likely because of a risk of infection, powerlessness, or a risk for impaired parent/infant attachment.

A client presents at 41 weeks gestation for induction of labor and an attempt at VBAC. The nurse is aware that which method would be contraindicated for this client?

Dinoprostone vaginal insert Because uterine hyperstimulation is a potential side effect that is not rapidly reversed with the use of dinoprostone vaginal insert, it is contraindicated in a woman with a history of previous cesarean delivery. Hyperstimulation is also a potential side effect of oxytocin infusion, but it can be quickly reversed by turning off the infusion. This makes the use of oxytocin safe for use in women with a previous cesarean. AROM and balloon catheter insertion are not noted to result in uterine hyperstimulation.

A multigravid woman has been in labor for several hours and has dilated to 8 cm. Her fetal membranes have not yet ruptured and her contractions are not as strong as the birth attendant would like them to be. The decision is made to artificially rupture the woman's membranes. The LPN/LVN is new on the unit. What is the LPN/LVN's role in this procedure?

Document fetal heart rate before and after the procedure. When assisting with amniotomy, document the fetal heart rate before and after the procedure. Notify the RN or birth attendant if the rate drops precipitously. Sometimes the birth attendant will ask for suprapubic or fundal pressure during the procedure. It is permissible to give this assistance, if you have been properly trained to do so.

The nurse is caring for a client who experienced an emergency cesarean birth. During the course of the client's care, the client exhibits impaired parent-infant attachment related to an unplanned method of birth, and anxiety related to unanticipated circumstances surrounding birth. Which interventional focus may have improved this client's outcomes?

Establishing an early helping relationship Establishing an early helping relationship with both the client and her support person is an interventional focus that allows the nurse to support the client more effectively should the birth method need to be changed. Coordinating health care team members is an essential function for supporting the client's continuity of care, but does not directly address anxiety or impaired attachment. Providing education may be a helpful part of reducing the client's anxiety, but the effectiveness of the education will be better supported by an established helping relationship. Giving opportunities for reviewing and integrating the experience is a helpful interventional focus given the client's current situation, but is not a helpful preventative measure to address risk for anxiety and impaired attachment.

The nurse is monitoring the labor of a woman attempting a vaginal birth after cesarean (VBAC) delivery. The nurse correctly suspects a uterine rupture when which of the following occur? Select all that apply.

Excessive maternal pain Increased vaginal bleeding Unrelenting uterine contraction Signs of maternal shock Onset of fetal bradycardia, not tachycardia, is noted with uterine rupture. The other choices are indicative of uterine rupture.

The nurse is caring for a client following a cesarean birth who received a low segment incision. Which outcome is possible for the client?

Experiencing vaginal delivery during future births Vaginal delivery after cesarean birth is possible for clients who have received a low segment incision during cesarean birth. A low segment incision does not increase the risk of placenta previa, require future cesarean births, or prolong hospitalization.

The nurse is caring for a postoperative client who has experienced a cesarean birth. For which related urinary complication should the nurse monitor?

Inability to sense fullness A cesarean birth involves handling and displacing the bladder anteriorly, which can cause the inability to sense bladder fullness for the client. Foul-smelling urine, pelvic pain, and dysuria are concerning findings, but are not directly related to the cesarean birth procedure.

A nurse correctly recognizes which of the following as a current trend within the population of birthing women?

Increased rates of cesarean sections. Cesarean sections are increasing in frequency across North America. Providers are using more medical interventions during birth, including epidurals. Doula services are not covered by health insurance and are either privately funded or provided by volunteers for at-risk populations.

It was once thought that an episiotomy made the birth less painful and heal faster than a spontaneous laceration of the perineum. Research has not shown these assumptions to be true. What is another finding in the research on episiotomies?

Increases risk of blood loss immediately after delivery Episiotomy increases the risk of blood loss immediately after delivery and contributes to painful sex in the months following delivery.

An elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor?

Induced labor can result in higher costs for the delivery. Simpson and Thorman (2005) caution against elective induction unless the woman understands that elective inductions often result in more interventions, longer labors, higher costs, and possible cesarean birth.

The maternal health nurse assists the health care provider during an artificial rupture of membranes procedure. Which direct outcome does the nurse expect?

Release of prostaglandins Artificial rupture of membranes (AROM), also known as amniotomy, can be done to induce labor or augment labor that has already begun. The direct outcome of AROM is the release of prostaglandins. Relief of pressure, decreased impedance on the birth canal, and increased strength of uterine contractions do not occur as a direct outcome of AROM.

A nurse assisting in a cesarean birth should essentially demonstrate understanding of which of the following?

Skill in either a scrubbing or circulating role The nurse would be required to demonstrate her skill in either a scrubbing or circulating role when assisting in a cesarean birth since caesarean births involve surgical procedures. Having an understanding of oxytocin pharmacology, knowing the complications of uterine hyperstimulation, and an understanding of non-reassuring fetal heart rate tracings are associated with the procedure of induction for vaginal birth and not with the surgical procedures involved in cesarean births.

The nurse is caring for a client who is insisting on a vaginal delivery. For which situation should the nurse explain a vaginal delivery is contraindicated? Select all that apply.

Spina bifida Transverse lie Suspected macrosomia, preterm delivery, and breech presentation as an isolated factor are not absolute contraindications for vaginal delivery, even though many healthcare providers prefer to perform a cesarean in these situations. Transverse lie and spina bifida are an absolute contraindication to a vaginal delivery.

The nursing instructor is conducting a session exploring the various factors related to induction of labor. The instructor determines the session is successful after the students correctly choose which factors are used to determine if the cervix is ripe enough for induction?

Station, effacement, cervical consistency, dilatation, and cervical position The health care provider may determine cervical readiness or "ripeness" by using the Bishop score. This is based on 5 factors: dilatation, effacement, station, cervical consistency, and position of the cervix. Each factor is given a score of 0 to 3. A total score of 8 or higher indicates that the cervix is considered ready for birth and should respond to induction. Attitude and presentation are not included in the score as they represent the position of the fetus and not the condition of the cervix.

The nurse is teaching deep breathing exercises to a client following a cesarean birth. What items should the nurse include in the teaching? Select all that apply.

Take 5 to 10 deep breaths Inhale as deeply as possible Hold breath for 1 to 2 seconds Repeat every hour A typical deep breathing exercise is to take 5 to 10 deep breaths every hour, inhaling as deeply as possible, holding the breath for a second or two, and then exhaling as deeply as possible. It is important to inhale and exhale fully to prevent light-headedness from hyperventilation.

The maternal health nurse is caring for a group of pregnant clients. Which client will the nurse determine is most ready for labor?

The client whose Bishop score is 9 today. The health care provider may determine cervical readiness using the Bishop score. Five factors are evaluated in the Bishop score: cervical consistency, position, dilation, effacement, and fetal station. The higher the score, the greater the chance that induction will be successful. A Bishop score of 9 indicates a "ripe" cervix that is ready for labor. Fetal fibronectin is a protein found in fetal membranes and amniotic fluid. Measuring fetal fibronectin levels in cervical secretions has also been studied for predicting labor readiness. A negative fetal fibronectin may indicate that the client is not yet ready for labor. Although a client who is 41 weeks gestation is "overdue", this does not indicate that the client's cervix is ready for labor. While measurement of the cervical length via endovaginal ultrasound may be used to determine readiness for labor, labor readiness is manifested by a shortening of the cervical length.

The maternal health nurse is caring for a group of clients in active labor attempting a vaginal birth. Which client will the nurse assess first?

The client with a previous classical uterine incision The risk for uterine rupture during VBAC is much higher when a woman has a classical uterine incision from a previous cesarean birth; therefore, this client should be assessed first because a VBAC is contraindicated due to the risk of uterine rupture. The client with a history of hypertension may or may not have controlled hypertension and is not the priority. A positive streptococcal culture requires antibiotic treatment; however, this is not the priority among the presented clients. A client with a previous placenta previa may or may not have the condition and is not a priority among the presented clients.

A woman having a cesarean birth will have a low cervical incision. Which of the following would you cite as an advantage?

The skin incision will be just above her pubic hair. A low cervical incision provides the best access to the fetus and the best cosmetic appearance to the mother.

Place the following events in order of occurrence for administration of spinal anesthesia before an elective primary cesarean delivery in a woman who is not in labor.

The woman enters the OR. The nurse instructs the patient to sit and make a C-curve with her back. The anesthesiologist cleanses the back. Spinal anesthesia is administered. The patient lies down on the delivery table, and a wedge is placed. The woman enters the OR. For spinal anesthesia, she sits on the OR table. The nurse instructs her to make a C-curve with her back. The anesthesiologist palpates for the correct spinal placement. The anesthesiologist then cleanses the back and administers the spinal anesthesia. The woman is then placed supine with a wedge under her back to prevent supine hypotension.

A client is being prepared for a scheduled cesarean delivery by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post cesarean delivery?

Urinary output It will be critical to carefully monitor the client's kidney function by monitoring her urinary output. This may include maintaining the Foley catheter for the first 24 hours to ensure accurate measurements of urinary output. Sodium citrate may be administered before surgery to help minimize gastric upset. Maintaining the IV access will depend on the client's situation, however, it is not the priority that monitoring her kidney function is.

The maternal health nurse is assisting a birth attendant in the use of low-outlet forceps for a forceps-assisted birth. At which point of the birth will the nurse expect the use of the device?

When the fetal station is equal or greater than +2 Low-outlet forceps are used when the fetal station is equal or greater than +2. Midforceps are most often used to assist the fetus in rotating to an anterior position. Outlet forceps are applied when the fetal head can be seen at the introitus. Midforceps are used when the fetal head is well engaged but still relatively high in the pelvis (higher than +2).

The nurse is caring for a woman who has had a baby by cesarean birth. Which of the following would be the most important assessment to make?

Whether her abdomen is soft or not A tense, "guarded" abdomen is one of the first signs of peritonitis.

A cesarean delivery is a major surgery and carries with it many risks for complications. The most common complication is infection. At what site is the infection likely to occur?

Uterus The most common postoperative complication associated with cesarean birth is infection. Two common infection sites are the uterus and the surgical wound, although sepsis, urinary tract infection, and other infections also can occur.

A patient having a cesarean birth will have a low segment incision. What should the nurse explain to the patient as an advantage for this type of incision?

Vaginal deliveries can occur with future births. Because a low segment incision is through the nonactive portion of the uterus, it is less likely to rupture in subsequent labors, making it possible for a woman to have a vaginal birth after cesarean with a future pregnancy. This type of incision is not vertical. The cervix is not cut with this type of incision. This type of incision has no impact on the ability to resuscitate the infant if necessary.

There is much discussion in the medical community about vaginal birth after a cesarean delivery (VBAC). When a woman has had a previous emergency cesarean delivery, she is at high risk for a ruptured uterus. When is VBAC contraindicated?

When a classical uterine incision has been made previously The risk for uterine rupture during VBAC is much higher when a woman has a classical uterine incision from a previous cesarean delivery; therefore, VBAC is contraindicated when this type of scar is present.

Following a cesarean birth, a patient is prescribed to receive intravenous fluids. At which time should the nurse anticipate that this patient will be able to resume an oral intake?

When bowel sounds return Patients are kept at "nothing by mouth" status for a period of time after surgery until intestinal peristalsis has returned. To establish this is returning, the patient's abdomen should be assessed at least once every 8 hours for bowel sounds because this demonstrates air and fluid are moving through the intestines. As soon as bowel sounds return, IV fluid therapy is usually discontinued and the patient can slowly begin oral intake with fluids. Oral intake may or may not be permitted 24 to 48 hours after the procedure. Oral intake is not contingent on bladder tone.

The type of skin incision done for a cesarean section will indicate the type of uterine incision.

false The type of skin incision does not indicate the type of uterine incision during a cesarean section. If the woman's obstetric history is unknown, the surgeon will ask to see the previous surgical record to determine the type of uterine incision.

The physician has just examined the patient and determined that she needs to have a cesarean section. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision:

reduces the risk of uterine rupture. The incision in the low cervical vertical incision is smaller than a classical incision. The low cervical vertical incision is more complicated to perform and has a higher risk of maternal injury. The low cervical vertical incision reduces the risk of uterine rupture.

A primigravida is admitted to the labor-and-delivery suite for an elective induction with oxytocin. The nurse caring for this client knows that one of the risks with oxytocin inductions is:

uterine hyperstimulation. There is a higher risk that a cesarean birth will become necessary whenever labor is induced. This is particularly true for primigravidas. There is also a risk that the uterus will be hyperstimulated. Hyperstimulation leads to contractions that occur one after the other without a sufficient rest period in between.