Chapter 16 Questions
Which test would provide evidence of fetal blood in maternal circulation? 1 Positive fern test 2 Positive Coomb's test 3 Positive Kleihauer-Betke 4 Negative Coomb's test
3 A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation. A positive fern test would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coomb's test would indicate that the mother has Rh antibodies. A negative Coomb's test would indicate no presence of Rh antibodies.
A pregnant patient who is in preterm labor has been prescribed dexamethasone (Decadron). What benefit of the drug would the nurse identify in the patient? 1 Maturation of fetal lungs 2 Relaxation of smooth muscles 3 Inhibition of uterine contractions (UCs) 4 Central nervous system (CNS) depression
1 Dexamethasone (Decadron) is a glucocorticoid and is administered to patients having preterm labor because it promotes fetal lung maturation. The drug facilitates the release of enzymes that induce production or release of lung surfactant. Tocolytics are used to inhibit UCs. Magnesium sulfate is a CNS depressant. Tocolytics also cause the relaxation of smooth muscles.
The nurse is assisting a woman in labor who has falling blood pressure, pain between the scapulae, abdominal tenderness, and fetal tachycardia. What intrapartum emergency does the nurse suspect? 1 Uterine rupture 2 Uterine inversion 3 Prolapsed umbilical cord 4 Anaphylactoid syndrome
1 Manifestations of uterine rupture vary with the degree of rupture and may mimic other complications. Possible signs and symptoms of uterine rupture include hypovolemic shock (tachycardia, tachypnea, falling blood pressure, pallor, cool and clammy skin, and anxiety); chest or shoulder pain, pain between the scapulae, or pain on inspiration because of the irritation of blood below the woman's diaphragm; abdominal pain and tenderness; impaired fetal oxygenation (late decelerations, reduced variability, tachycardia, bradycardia); absent fetal heart sounds or activity cessation of uterine contractions; and palpation of the fetus outside the uterus (usually occurs only with a large, complete rupture). This patient is not showing signs of uterine inversion, prolapsed umbilical cord, or anaphylactoid syndrome.
The fetal fibronectin test of a pregnant patient is positive, and her cervical length is found to be 32 mm. What will the nurse interpret from these observations regarding the patient's pregnancy status? 1 Normal gestation labor 2 Indicated preterm labor 3 Spontaneous preterm labor 4 Miscarriage in the next week
1 The cervical length and fibronectin test help to identify the risk of preterm delivery in the patient. If the cervical length of the patient is greater than 30 mm, the patient would not have preterm labor, irrespective of having the symptoms of preterm labor. Because the cervical length of the patient is 32 mm, the patient may have normal gestational labor. Cervical length and the fibronectin test do not indicate whether the patient would have a miscarriage. If the cervical length is less than 30 mm, the patient may have indicated or spontaneous preterm labor.
What are the possible risk factors associated with indicated preterm birth? Select all that apply. 1 Herpes infection 2 Gestational diabetes 3 Chronic hypertension 4 History of preterm birth 5 Second trimester bleeding
1,2,3 Preterm births can be either spontaneous or indicated. Conditions that pose a danger to fetal or maternal health may be resolved by indicated preterm birth. These conditions include herpes infection, gestational diabetes, and hypertension in the mother. The patients with these conditions undergo indicated preterm birth to ensure the neonate's safety. Patients with a history of preterm birth and second trimester bleeding are at risk of spontaneous preterm birth.
During a prenatal visit, the nurse finds that the patient has decreased mobility and symptoms of preterm labor. Which nursing intervention is to be followed to prevent thrombophlebitis? 1 Teach gentle lower-extremity exercises to the patient. 2 Suggest that the patient lie in the supine position in bed. 3 Provide a calm and soothing atmosphere to the patient. 4 Give tocolytic medications as per the physician's prescription.
1 The health care provider may recommend reduced activity for the patient experiencing preterm labor, depending on the severity of the symptoms. As a result, the patient may be at risk for thrombophlebitis due to limited activity. The nurse should teach the patient how to perform gentle exercises of the lower extremities. Suggesting that the patient lie in the supine position may cause supine hypotension. Instead, the nurse can suggest that the patient lie in a side-lying position to help enhance placental perfusion. The nurse can provide a calm and soothing atmosphere to facilitate coping so as to reduce the patient's anxiety, but this intervention does not prevent thrombophlebitis. Tocolytic medications are given to the patient to
The nurse is assessing a pregnant patient who takes nifedipine (Adalat). What instruction does the nurse provide to ensure the patient's safety? 1 Consume adequate fluids. 2 Take medication on an empty stomach. 3 Avoid eating foods high in carbohydrates. 4 Administer medication under medical supervision.
1 The potent vasodilator effect of nifedipine (Adalat) causes variations in the blood pressure of a pregnant patient. So the nurse advises the patient to consume adequate fluids to maintain blood pressure. Nifedipine (Adalat) is best tolerated when taken with food. Hence, the nurse does not ask the patient to take the medication on empty stomach. Patients on glucocorticoids are advised to avoid carbohydrate-rich foods because glucocorticoids increase glucose levels in the body, and are unrelated to nifedipine (Adalat). Nifedipine (Adalat) is taken orally and does not require medical supervision to administer it.
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? 1 Place the woman in the knee-chest position. 2 Cover the cord in a sterile towel saturated with warm normal saline. 3 Prepare the woman for a cesarean birth. 4 Start oxygen by face mask.
1 The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. If the cord is protruding from the vagina it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. The nurse should administer oxygen by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.
The nurse is caring for a pregnant patient who had an onset of labor during 34 weeks' gestation. What does the nurse expect the primary health care provider to prescribe? Select all that apply. 1 Antibiotics 2 Glucocorticoids 3 Synthetic oxytocin 4 Magnesium sulfate 5 Progesterone supplementations
1,2 The onset of labor during 34 weeks' gestation indicates that the patient has preterm labor. In such a condition, antibiotics and glucocorticoids should be prescribed and administered to the patient. Antibiotics are prescribed to prevent neonatal group B streptococcal infection. Glucocorticoids are prescribed to reduce the neonatal morbidity and mortality. Synthetic oxytocin is administered in patients to induce labor. Therefore synthetic oxytocin will not be prescribed to the patient because of the onset of labor. Magnesium sulfate is administered when the labor is induced before 32 weeks' gestation. Progesterone supplementation is administered before the onset of labor to prevent preterm birth.
What are maternal risk factors for preterm labor? Select all that apply. 1 Obesity 2 Periodontal disease 3 Low weight for height 4 Cervical length less than 20 mm at midtrimester 5 History of three or more previous pregnancy losses
1,2,3 Maternal risk factors for preterm labor include obesity, periodontal disease, low weight for height, cervical length of less than 25 mm at midtrimester, and history of two or more previous pregnancy losses.
A woman in labor with her first child expresses fear related to pain and her perceived inability to cope with labor. The nurse caring for the patient knows this fear may interfere with normal labor progress by decreasing energy, releasing catecholamines, and increasing muscle resistance. Which nursing interventions can most effectively assist the patient in relaxing and help her body work more effectively with the forces of labor? Select all that apply. 1 Establishing a trusting relationship with the woman and her significant other 2 Making the environment comfortable by adjusting temperature and light 3 Identifying coping measures the patient finds useful 4 Promoting physical comfort such as cleanliness 5 Sharing only minimal information regarding labor progress with the patient 6 Implementing nonpharmacologic and pharmacologic pain management
1,2,3,4,6 Establishing a trusting relationship with the woman and her significant other, making the environment comfortable by adjusting temperature and light, identifying coping measures the patient finds useful, promoting physical comfort such as cleanliness, and implementing nonpharmacologic and pharmacologic pain management are effective nursing interventions to help the patient relax and help labor progress. Providing only minimal information to the patient regarding labor progress can increase the patient's stress and anxiety and prolong labor.
A precipitous birth is associated with which potentially serious conditions? Select all that apply. 1 Placental abruption 2 Fetal meconium 3 Maternal postpartum hemorrhage 4 Fetal hemorrhage 5 Low Apgar scores
1,2,3,5 Precipitous births are associated with placental abruption, fetal meconium, maternal postpartum hemorrhage, and low Apgar scores. It is not associated with fetal hemorrhage.
The nurse observes that a patient has a high fever, maternal and fetal tachycardia, uterine tenderness, and vaginal discharge with a foul odor in early labor. Which signs should the nurse assess in the neonate? Select all that apply. 1 Seizures 2 Breathing difficulties 3 Laceration on the head 4 High body temperature 5 Heart rate of 110 beats per minute
1,2,4 Fever, maternal and fetal tachycardia, uterine tenderness, and vaginal discharge with a foul odor are the signs of a bacterial infection called chorioamnionitis. Women with chorioamnionitis are more likely to have a cesarean birth due to dysfunctional labor. Neonatal risks include pneumonia, sepsis, and cerebral palsy. Therefore, the nurse should monitor signs like seizures (indicative of cerebral palsy), breathing difficulties (indicative of pneumonia), and a high body temperature (indicative of sepsis) in the neonates of these patients. Neonates who are born through forceps- or vacuum-assisted birth may have a laceration on the head; however, this is not associated with chorioamnionitis. A heart rate of 110 beats/minute is a normal observation in newborns and is not a serious sign.
While providing care to a pregnant woman in the active stage of labor, the nurse observes that labor has not progressed in over an hour. Which interventions does the nurse utilize to resolve the labor dystocia? Select all that apply. 1 Administering adequate intravenous (IV) or oral fluids 2 Having the patient stand or sit in the shower 3 Having the patient take a warm tub bath 4 Providing pain management 5 Calling for initiation of the ordered epidural block 6 Assisting the patient in changing position
1,2,4,6 Administering adequate IV or oral fluids can correct maternal fluid and electrolyte imbalances or hypoglycemia. Standing or sitting in a shower provides the comfort of warm water and an upright position. Effective pain management may improve the progress of labor. The woman who actively changes positions typically has better labor progress and is more comfortable than the woman who remains in one position. A tub bath is contraindicated because the heat may cause the woman to become dizzy and fall. Additionally, if the membranes are ruptured it may introduce bacteria into the fetal environment. Initiating an epidural block may reduce the effectiveness of contractions.
What are the causes of indicated preterm labor? Select all that apply. 1 Herpes infection 2 Multifetal gestation 3 Gestational diabetes 4 Chronic hypertension 5 Second trimester bleeding
1,3,4 Preterm labor may be spontaneous or indicated. Indicated preterm labor is a means to resolve the maternal and fetal risk. The factors that can cause indicated preterm labor include gestational diabetes, chronic hypertension, and herpes infection. Spontaneous preterm labor is caused due to early initiation of the labor process. The factors responsible for spontaneous labor are multifetal gestation and bleeding during the second trimester.
A woman in labor experiences severe back pain and delayed labor progress because the fetus is in an occiput posterior position. Into which positions can the nurse help the patient in order to promote fetal rotation? Select all that apply. 1 Side-lying 2 Supine 3 Hands and knees 4 Squatting 5 Sitting 6
1,3,4,5,6 The side-lying and hands-and-knees positions promote rotation because the mother's abdomen is dependent in relation to her spine. Squatting (for second-stage labor) helps expand the pelvic space so the fetus may rotate. Sitting, kneeling, or standing while leaning forward help promote descent, which usually is accompanied by fetal head rotation. Lying supine increases pressure on the maternal spine and the uterus and decrease the fetus's ability to rotate.
Which factors increase a woman's risk for a prolapsed umbilical cord in the presence of ruptured membranes? Select all that apply. 1 Hydramnios 2 Preterm labor 3 Oligohydramnios 4 Fetus that poorly fits the pelvic inlet 5 Fetal presenting part at a high station
1,4,5 Factors that increase a woman's risk for a prolapsed umbilical cord include ruptured membranes and hydramnios, a fetus that poorly fits the pelvic inlet because of small size or abnormal presentation, or the fetal presenting part at a high station. Hydramnios and preterm labor are not risk factors for prolapsed umbilical cord.
While assisting a primary health care provider performing amniotomy, the nurse observes part of the umbilical cord protruding from the patient's vagina. The nurse immediately positions the patient in the Trendelenburg position and inserts a finger into her vagina. What additional care does the patient need to prevent complications? 1 Perform large-bore catheter suction. 2 Prepare for an emergency C-section. 3 Administer calcium gluconate intravenously. 4 Administer terbutaline (Brethine) subcutaneously.
2 Amniotomy may cause prolapse of the umbilical cord, in which the cord lies below the presenting part of the fetus. A prolapsed cord causes fetal hypoxia because the supply of oxygen to the fetus is reduced. A cesarean birth should be performed to prevent further complications. Large-bore catheter suction is performed to remove the aspirated meconium from the newborn, and is unrelated to cord prolapse. Calcium gluconate is administered to a pregnant patient who develops magnesium sulfate toxicity. Calcium gluconate is unrelated to cord prolapse. Terbutaline (Brethine) is administered to treat tachysystole in the pregnant patient and is unrelated to cord prolapse.
In what situation during labor is the infant's head and/or shoulders too large to adapt to the pelvis? 1 Placental abruption 2 Cephalopelvic disproportion 3 Occiput posterior (OP) position 4 Breech presentation
2 Cephalopelvic disproportion occurs when the fetal head or shoulders are too large to adapt to the maternal pelvis. Placental abruption occurs when the placenta disengages from the uterus prior to the birth of the infant. The infant is in the OP position when the back of the skull is in the back of the mother's pelvis. An infant is in breech position when the buttocks or feet are positioned to be delivered first.
The nurse is caring for a pregnant mother whose membranes ruptured at 32 weeks. The nurse explains that a seal has formed, stopping the fluid leak and allowing the amniotic fluid cushion to become reestablished. For what does the nurse continue to monitor the patient? 1 Macrosomia 2 Oligohydramnios 3 Precipitous labor 4 Maternal exhaustion
2 Membranes that rupture before term may form a seal, stopping the fluid leak and allowing the amniotic fluid cushion to become reestablished. However, membranes may continue to leak, resulting in low levels of amniotic fluid (oligohydramnios), prolonging the loss of the amniotic fluid cushion for the fetus. Macrosomia, precipitous labor, and maternal exhaustion are not necessarily relevant for this patient.
What defines oligohydramnios? 1 Amniotic fluid index of 4 cm or less or a single deep pocket of 1 cm or less 2 Amniotic fluid index of 5 cm or less or a single deep pocket of 2 cm or less 3 Amniotic fluid index of 6 cm or less or a single deep pocket of 3 cm or less 4 Amniotic fluid index of 7 cm or less or a single deep pocket of 4 cm or less
2 Oligohydramnios is defined as amniotic fluid index of 5 cm or less or a single deep pocket of 2 cm or less on ultrasound. It is not defined as amniotic fluid index of 4, 6, or 7 cm or less or a single deep pocket of 1, 3, or 4 cm or less.
A pregnant patient has painful lower abdominal cramps and a mucoid vaginal discharge. Upon further examination, the nurse concludes that the patient may have a low risk of having a preterm delivery. What finding led the nurse to this conclusion? 1 The patient had a previous cesarean birth. 2 The patient has a cervical length of 40 mm. 3 The patient has preexisting diabetes mellitus. 4 The patient has symptoms of chronic hypertension
2 Painful, lower abdominal cramps and a mucoid vaginal discharge are symptoms of preterm labor. The cervical length is a good predictor of preterm birth. Women whose cervical length is greater than 30 mm are unlikely to experience premature birth, even if they have symptoms of preterm labor. The cervix needs to prepare itself for childbirth in terms of effacement and dilatation. A previous cesarean birth does not indicate that the woman will likely not have a preterm delivery. Preexisting diabetes and chronic hypertension are preterm birth risk factors.
Periviable birth is defined as birth at how many weeks' gestation? 1 15 to 20 2 20 to 25 3 25 to 30 4 30 to 35
2 Periviable birth is defined as birth at 20 0/7 weeks to 25 6/7 weeks' gestation. It is not birth at 15 to 20, 25 to 30, or 30 to 35 weeks' gestation.
A patient diagnosed with placenta accreta has uncontrolled bleeding, despite administering medications. What should be the best choice for treatment in this situation? 1 Massage the uterus 2 Prepare the patient for surgery 3 Replace blood components as needed 4 Apply traction on the umbilical cord
2 Placenta accreta is an obstetric complication in which the placenta adheres to and penetrates the myometrium. The patient with placenta accreta is at risk of having hemorrhage during childbirth. If bleeding is not stopped after the administration of medication to the patient, then a hysterectomy has to be performed to prevent further complications. Replacement of blood components is not useful, because the patient has uncontrolled bleeding. Massaging the uterus and applying traction to the umbilical cord is helpful to expel the placenta, but is not useful when the placenta is adhered to the uterus.
With regard to dysfunctional labor, nurses should be aware of what? 1 Women who are underweight are more at risk. 2 Women experiencing precipitous labor have a labor that lasts less than 3 hours. 3 Hypertonic uterine dysfunction is more common than hypotonic dysfunction. 4 Abnormal labor patterns are most common in younger women.
2 Precipitous labor lasts less than 3 hours. Short women who are more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in older women.
Preterm labor is defined as labor that occurs between which weeks of pregnancy? 1 20 to 30 2 20 to 37 3 27 to 37 4 30 to 37
2 Preterm labor begins after the 20th week but before the start of the 37th week of pregnancy. It is not defined as that which occurs between weeks 20 and 30, 27 and 37, or 30 and 37 of pregnancy.
The nurse is caring for a patient with premature rupture of membranes (PROM). How should the nurse instruct the patient to manage the situation? 1 "Consume excess amounts of fluids." 2 "Assess fetal movement on a daily basis." 3 "Monitor the skin for any discoloration." 4 "Place yourself in the Trendelenburg position."
2 The nurse should instruct a pregnant patient with PROM to perform daily fetal movement counts. Reduction in fetal movements indicates fetal dysfunction. Patients who are administered tocolytic agents, such as nifedipine (Adalat), are instructed to consume excess fluids to prevent effects of vasodilatation. Consumption of excess fluids is unrelated to the management of PROM. Skin discoloration is observed in conditions like jaundice, but not in patients with PROM. The nurse places the patient in the Trendelenburg position if the patient has symptoms of umbilical cord prolapse.
Since bladder distention reduces available space in the pelvis and intensifies maternal discomfort, the nurse ensures that the patient in labor is encouraged to void at which interval during labor? 1 Every 30 minutes 2 Every 1 to 2 hours 3 Every 2 to 3 hours 4 Every 3 to 4 hours
2 The woman in labor should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Encouraging the woman to void every 30 minutes is too frequent. An interval any longer than 2 hours (such as 2 to 3 hours or 3 to 4 hours) can result in a full bladder and soft tissue obstruction.
The nurse is preparing to administer dexamethasone (Decadron) to a pregnant patient. Which nursing intervention should the nurse perform for safe administration of the drug? Select all that apply. 1 Monitor blood pressure of the patient. 2 Inform the patient that it will be painful. 3 Assess blood glucose levels in the patient. 4 Administer the drug by intramuscular injection. 5 Administer the oral form if the patient refuses injection.
2,3,4 Dexamethsone (Decadron) is a glucocorticoid used to promote fetal lung maturation. The drug can also increase blood sugar levels in the patient. Therefore the nurse should monitor the blood sugar levels to assess the need for an increased insulin dose. The drug should be given by intramuscular injection in the ventral gluteal or vastus lateralis muscle for better absorption. The patient should be informed that the injection will be painful, because this type of truthfulness promotes patient cooperation. The drug does not affect blood pressure levels and it does not need to be monitored. The oral form is not beneficial in promoting fetal lung maturation and should not be administered.
The nurse observes that a patient has a decreased uterine size and has lost 5 lb at 42 weeks of gestation. Which signs should the nurse assess in the neonate after birth? Select all that apply. 1 Seizures 2 Long nails 3 Dry and peeling skin 4 High body temperature 5 Meconium-stained skin
2,3,5 Reduced uterine size and a maternal weight loss of 3 lb/week or more are clinical manifestations of postterm pregnancies. Postterm infants are at an increased risk of meconium aspiration. These infants are most likely to have postmaturity syndrome, which is characterized by long nails, dry and peeling skin, and meconium-stained skin. Seizures (indicative of cerebral palsy) and high body temperature (indicative of sepsis) are the complications associated with infants who are born to women with chorioamnionitis during labor
The nurse is assisting a mother during labor who has increased blood pressure and respiration. The patient states, "I can't do this anymore. I'm too tired to have this baby." What interventions should the nurse apply? Select all that apply. 1 Brighten the lights to stimulate the patient. 2 Employ back massage to reduce muscle tension. 3 Reduce noise or play soft music to relax the patient. 4 Encourage the patient to remain as still as possible to conserve energy. 5 Offer the patient a blanket or fan to maintain a comfortable temperature.
2,3,5 The patient is showing signs of exhaustion. Therefore, the nurse should apply interventions to conserve maternal energy, including back massage to reduce muscle tension, reducing noise or playing soft music to relax the patient, and offering a blanket or fan so the patient can maintain a comfortable temperature. The nurse should not brighten the lights to stimulate the patient; dimming the lights will help her relax. The nurse should not encourage the patient to remain still; changing positions every 30 minutes will help reduce muscle tension from constant pressure.
The nurse is caring for an infant born at 28 weeks of gestation. Which complication can the nurse expect to observe during the course of the infant's hospitalization? Select all that apply. 1 Polycythemia 2 Respiratory distress syndrome 3 Meconium aspiration syndrome 4 Periventricular hemorrhage 5 Persistent pulmonary hypertension 6 Patent ductus arteriosus
2,4,6 Respiratory distress syndrome, periventricular hemorrhage, and a patent ductus arteriosus are common complications with preterm infants. Polycythemia, meconium aspiration syndrome, and persistent pulmonary hypertension are complications of postmaturity.
What term describes a birth occurring when a trained attendant is not present to assist? 1 Macrosomia 2 Labor dystocia 3 Precipitous birth 4 Precipitous labor
3 A precipitous birth occurs after a labor of any length, in or out of the hospital or birth center, when a trained attendant is not present to assist. Macrosomia describes an infant weighing more than 8 lb 13 oz (4000 g) at birth. Labor dystocia means a difficult labor and may be used to describe any form of dysfunctional labor. Precipitous labor is not the same as a precipitous birth. Precipitous labor is one in which birth occurs within 3 hours of its onset. Intense contractions often begin abruptly rather than gradually increasing in frequency, duration, and intensity, as is typical of most labors.
The nurse is teaching a group of pregnant patients about preterm labor and the actions to take if the signs and symptoms of preterm labor develop. Which patient statement indicates the need for further teaching? 1 "I will empty my bladder immediately." 2 "I will drink 2 to 3 glasses of water or juice." 3 "I will lie in the supine position for 1 hour." 4 "I will go to hospital if symptoms continue
3 If there are signs and symptoms of preterm labor, the patient should lie down on her side for 1 hour because it helps improve placental and fetal circulation. The patient should empty her bladder immediately because a full bladder may sometimes irritate the uterus. Dehydration may also irritate the uterus. Therefore, the patient should drink 2 to 3 glasses of water or juices. The patient should go to the hospital if the symptoms of preterm labor do not subside.
What term describes a failure to quickly progress during the active stage of labor? 1 Macrosomia 2 Tachysystole 3 Labor dystocia 4 Precipitous labor
3 Labor dystocia means a difficult labor and may be used to describe any form of dysfunctional labor. However, it is most often used to describe labor that does not progress as expected. When labor dystocia, or "failure to progress," occurs, contractions are coordinated but too weak to be effective. Labor dystocia, or secondary arrest, occurs during the active phase of labor, when progress normally quickens. Macrosomia describes an infant weighing more than 8 lb 13 oz (4000 g) at birth. Tachysystole can be either spontaneous or induced and is defined as excessive uterine activity. Tachysystole is characterized by more than five contractions in 10 minutes, averaged over 30 minutes. Precipitous labor is one in which birth occurs within 3 hours of its onset.
What should nurses be aware of with regard to the use of tocolytic therapy to suppress uterine activity? 1 The drugs can be given efficaciously up to the designated beginning of term at 37 weeks. 2 There are no important maternal (as opposed to fetal) contraindications. 3 Its most important function is to afford the opportunity to administer antenatal glucocorticoids. 4 If the woman develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.
3 There are important maternal contraindications to tocolytic therapy. After the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Tocolytic-induced edema can be caused by IV fluids.
A patient had a previous cesarean birth. What are the criteria in order to try having a vaginal birth during the second pregnancy? Select all that apply. 1 A history of postpartum hemorrhage 2 A previous classical vertical incision 3 Clinically adequate pelvis 4 Previous low transverse incision 5 No history of uterine rupture
3,4,5 A vaginal birth is possible after a previous caesarean delivery if the pelvis is found to be adequate to provide room for childbirth. A previous low transverse incision poses less risk of rupture and a vaginal delivery may be possible. A patient with no history of uterine rupture would have less risk of uterine rupture during the vaginal delivery. A history of postpartum hemorrhage may not affect the risk associated with a second vaginal delivery in women with a history of first caesarean delivery. A previous vertical incision on the uterus increases the risk of uterine rupture.
What are the risk factors associated with preterm premature rupture of membranes (PROM)? Select all that apply. 1 Preeclampsia 2 Long cervical length 3 Cigarette smoking 4 Urinary tract infection 5 Uterine overdistention
3,4,5 Conditions such as smoking, urinary tract infection, and uterine overdistention may cause early rupturing of membranes in a pregnant patient. Therefore, these factors are considered risk factors associated with preterm PROM. Preeclampsia is the common cause of indicated preterm birth and is not associated with preterm PROM. Short cervical length would increase the risk of PROM and may not be observed in patients with long cervical length. Non-Caucasian women are at a higher risk for spontaneous preterm birth than Caucasian women.
The nurse is assisting a woman in labor who rapidly develops abrupt respiratory distress, depressed cardiac function, and circulatory collapse. What intrapartum emergency does the nurse suspect? 1 Uterine rupture 2 Uterine inversion 3 Prolapsed umbilical cord 4 Anaphylactoid syndrome
4 Anaphylactoid syndrome of pregnancy, often called amniotic fluid embolism syndrome, occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs. Fetal particulate matter (skin cells, vernix, hair, meconium) in the fluid obstructs pulmonary vessels. Failure of the right ventricle occurs early and can lead to hypoxemia. Left ventricular failure follows. Abrupt respiratory distress, depressed cardiac function, and circulatory collapse may occur rapidly. This infrequent disorder is often fatal, and survivors may have neurologic deficits. This patient is not showing signs of uterine rupture, uterine inversion, or prolapsed umbilical cord.
What side effects should the nurse be aware of in a pregnant patient who had been administered betamethasone (Diprolene)? 1 Hot flushes 2 Hypotension 3 Hypoglycemia 4 Increased white blood cells (WBCs)
4 Betamethasone (Diprolene) is a glucocorticoid administered to a patient who is at risk of preterm birth. The patient will have a transient increase in WBCs and elevated blood glucose levels as a side effect of the medication. Hot flushes are observed in patients who are administered magnesium sulfate (Epsom Salt), and nifedipine (Adalat) causes hypotension. These effects are not related to the administration of betamethasone (Diprolene). Betamethasone (Diprolene) causes hyperglycemia (increased blood glucose levels) as a side effect.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? 1 Estriol is not found in maternal saliva. 2 Irregular, mild uterine contractions are occurring every 12 to 15 minutes. 3 Fetal fibronectin is present in vaginal secretions. 4 The cervix is effacing and dilated to 2 cm.
4 Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor, such as cervical changes.
The nurse is caring for a neonate with intrauterine growth restriction (IUGR). The nurse observes that the neonate is restless, lethargic, and hypothermic. What immediate intervention does the nurse provide to ensure the neonate's safety? 1 Administer water feeding. 2 Provide ventilator support. 3 Stop formula feeding for 2 days. 4 Immediately assess the newborn's blood sugar level.
4 IUGR causes restricted growth patterns in the neonate, resulting in complications like hypoglycemia and polycythemia. Reduced body temperature (hypothermia) is characteristic of hypoglycemia. Restlessness and lethargy are other symptoms that indicate hypoglycemia. The nurse should immediately assess the blood sugar levels and administer dextrose if the blood sugar is found to be less. Water feeding is avoided in neonates, as it may cause water intoxication. Ventilator support is provided in the case of neonatal respiratory depression. Immediate formula feed or mother's milk should be encouraged for neonates with hypoglycemia.
The nurse is caring for a multiparous patient. In which stage can the nurse expect the fetal head to be engaged in the pelvic inlet? 1 About 2 weeks before term 2 Before the start of active labor 3 When labor stage I begins 4 After labor is established
4 In a multiparous patient, the abdominal musculature is relaxed. The fetal head often remains freely movable above the pelvic brim and becomes engaged in the pelvic inlet only after labor is established. In a nulliparous patient, the uterus sinks downward and forward about 2 weeks before term, when the presenting part of the fetus descends into the true pelvis. The fetal head is engaged in the pelvic inlet before the onset of active labor. The abdominal muscles are firm in a nulliparous pregnancy and direct the presenting part into the pelvis. The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix.
Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? 1 A primigravida who is 17 years old 2 A 22-year-old multiparous woman with ruptured membranes 3 A primigravida who has requested no analgesia during her labor 4 A multiparous woman at 39 weeks of gestation who is expecting twins
4 Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this woman's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
Which term is used to describe perforation of the uterus due to placental adherence to the uterine walls? 1 Placenta previa 2 Placenta increta 3 Placenta accreta 4 Placenta percreta
4 Placenta percreta is the condition in which the endometrium is perforated due to the adherence of the placenta. Placenta previa is a complication in which the placenta is implanted near the cervix. Deep penetration of the endometrium by the placenta is known as placenta increta. Placenta accreta is the condition in which the placenta penetrates slightly into the endometrium.
What term describes a birth occurring within 3 hours of the onset of labor? 1 Macrosomia 2 Labor dystocia 3 Precipitous birth 4 Precipitous labor
4 Precipitous labor is one in which birth occurs within 3 hours of its onset. Intense contractions often begin abruptly rather than gradually increasing in frequency, duration, and intensity, as is typical of most labors. Macrosomia describes an infant weighing more than 8 lb 13 oz (4000 g) at birth. Labor dystocia means a difficult labor and may be used to describe any form of dysfunctional labor. Precipitous labor is not the same as a precipitous birth. A precipitous birth occurs after a labor of any length, in or out of the hospital or birth center, when a trained attendant is not present to assist.
The nurse is administering glucocorticoids to a pregnant woman in preterm labor. When explaining the purpose of this medication to the patient, which response by the nurse is accurate? 1 To prevent fetal cerebral palsy 2 To prevent early birth of the fetus 3 To prevent gestational hypertension 4 To prevent fetal respiratory distress syndrome
4 Preterm birth causes respiratory distress in the newborn due to underdeveloped lung activity. Antenatal glucocorticoids are administered to a pregnant patient who is at the risk of preterm labor to prevent fetal respiratory distress syndrome. Tocolytic agents such as magnesium sulfate (Epsom salts) are found to reduce the incidence of cerebral palsy in the child, and are unrelated to glucocorticoids. Gestational hypertension is observed in patients who have a familial history of hypertension and may not be prevented by administering glucocorticoids. Glucocorticoids have no impact on delaying preterm birth.
For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? 1 Fetal heart rate of 120 beats/minute 2 Cervix dilated 2 cm and 50% effaced 3 Score of 8 on the biophysical profile 4 One fetal movement noted in 1 hour of assessment by the mother
4 Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. A fetal heart rate of 120 beats/minute is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a woman at 42 weeks of gestation. A score of 8 on the biophysical profile is a normal finding in a pregnancy at 42 weeks.
The primary health care provider prescribes terbutaline (Brethine) for a pregnant patient. As the nurse reviews the patient's medical record, what would be the rationale for this prescription? 1 Blood volume is elevated. 2 Hemoglobin is decreased. 3 Blood pressure is reduced. 4 Contractions are increased.
4 Terbutaline (Brethine) is administered to the patient who has premature labor. It slows down the contractions. Terbutaline (Brethine) has no effect on blood volume, blood pressure, and hemoglobin. Blood volume is elevated by infusing aggressive intravenous infusion or from sodium and water retention. Maternal hypotension, as evidenced by reduced blood pressure, is relieved by elevating the legs during labor. Patients with decreased hemoglobin are treated with iron supplements, not terbutaline (Brethine).
The nurse is preparing to perform a fetal fibronectin test for a pregnant patient. Which intervention should the nurse perform to collect the sample for the test? 1 Take a blood sample from the forearm. 2 Take a sample of patient's amniotic fluid. 3 Ask the patient to provide a urine sample. 4 Collect the vaginal secretions using a swab.
4 The fetal fibronectin test is conducted to assess whether a patient is at risk for preterm labor. Fetal fibronectin is a glycoprotein found in the vaginal secretions during early and late pregnancy. In order to conduct the test the nurse should collect the vaginal secretions using a swab and send it for analysis. Urine, blood, and amniotic fluid are not collected for a fetal fibronectin test because they may not contain adequate glycoprotein levels.
A laboring mother has a body temperature of 102.4˚F and purulent fluid emanating from the cervical os. What diagnosis applies to this patient? 1 Triple I 2 Double I 3 Confirmed triple I 4 Suspected triple I
4 Triple I is intrauterine inflammation or infection or both, and fever plus one indicator is considered suspected triple I. Triple I is also known as chorioamnionitis, intra-amniotic infection, or intrauterine infection. Double I is not a relevant diagnosis. Confirmed triple I is fever plus confirmed testing via positive Gram stain for bacteria or low amniotic fluid glucose.
The nurse is caring for a pregnant patient at 27 weeks of gestation who tests positive for fetal fibronectin (fFN). What is the nurse's priority action to manage this patient's care? 1 Administer tocolytic medication. 2 Admit the patient to the hospital. 3 Recommend full bed rest until full term. 4 Schedule more frequent prenatal appointments.
4 fFN is a protein present in the layers of the amniotic membrane. It is normally found in cervical and vaginal secretions until 16 to 20 weeks of gestation and again at or near term. If it appears too early, it suggests that labor may begin early. However, because its predictive value has not been supported by randomized clinical trials, and due to the low positive predictive value of the test, health care providers do not exclusively use fFN to direct the medical management of a woman with preterm contractions. Therefore, the nurse should schedule the patient for more frequent prenatal appointments to monitor her more closely. Tocolytic medication, hospital admission, and full bed rest are not indicated by positive fFN alone.
33. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurse's next action? a. Palpate the patient's bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.
ANS: A The fetal presenting part is expected to descend at a minimal rate of 1 cm/hour in the nullipara and 2 cm/hour in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs
ANS: A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.
32. Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction
ANS: A A patient attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.
15. A patient who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "You should come into the office and let the doctor check you." b. "Acetaminophen is acceptable during pregnancy. You should not take aspirin, however." c. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."
ANS: A A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The patient needs to be assessed for preterm labor before providing pain relief.
9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. palpate the infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.
ANS: A Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.
6. Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.
ANS: A Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.
12. A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the patient with her hips slightly elevated.
ANS: A Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
30. When reviewing the prenatal record of a patient at 42 weeks' gestation, the nurse recognizes that induction of labor is based upon which indication a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-lb weight gain at each of the last two weekly visits.
ANS: A Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-lb weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation.
34. Which patient is most at risk for a uterine rupture? a. A gravida 4 who had a classic cesarean incision b. A gravida 5 who had two vaginal births and one cesarean birth c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant
ANS: A The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The patient who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low-segment incisions do not raise the risk of uterine ruptures.
37. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area
ANS: A, B, C, E Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.
2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor
ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.
1. Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid
ANS: B The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes.
25. Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern
ANS: B A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and patients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure.
4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.
ANS: B A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.
14. The fetus in a breech presentation is often born by cesarean birth because a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the patient delivers vaginally.
ANS: B After the fetal legs and trunk emerge from the patient's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.
23. A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care? a. Administration of antihypertensive medication b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring
ANS: B Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient with this condition will be hypotensive, not hypertensive.
19. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the patient not to push until you prepare the vacuum extraction device for physician. d. Reposition the patient to facilitate birth.
ANS: B In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it may cause additional problems. Vacuum extraction will not help to resolve the birth issue and may lead to further complications. Repositioning of the patient may not be effective to relieve this condition and facilitate birth.
31. Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hour c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/minute
ANS: B In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hour; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/minute may be indications of hypovolemia.
5. Which technique is least effective for the patient with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees
ANS: B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.
28. Which finding would be indicative of an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL
ANS: B Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.
24. A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks' gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient's request? a. There is no way to tell if any complications would arise. Because the patient is not presenting with any problems, the nurse should call the health care provider and inform her or him of the patient's decision to go home and wait. b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the patient that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the patient will be sent home. d. Tell the patient that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physician's directions.
ANS: B The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the patient wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore it is best for the patient to remain in a supervised clinical setting. Indicating that the patient could possibly go home would place the patient at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.
38. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction
ANS: B, C, E Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus there is an increased risk for placental abruption as compared with placenta previa, which is based upon malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor.
27. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/minute. b. Stop the Pitocin infusion. c. Position the patient in the knee-chest position. d. Increase the main line infusion to 150 mL/hour.
ANS: C A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.
3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2C (99F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates
ANS: C Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.
13. Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of -3 d. Meconium-stained amniotic fluid
ANS: C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the patient at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.
20. A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test? a. Patient must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Patient should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.
ANS: C Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.
36. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency
ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.
29. A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours on March 12. The nurse knows that the next dose must be scheduled for a. 1430 hours on March 12th. b. 2030 hours on March 12th. c. 0830 hours on March 13th. d. 1430 hours on March 13th.
ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 1430 hours on March 12th, 2030 hours on March 12th, and 1430 hours on March 13th do not fall within this recommendation. The next dose should be scheduled for 0830 hours on March 13th.
22. A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent
ANS: C The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the patient should be prepped for a cesarean section.
7. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous patient with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous patient at 39 weeks of gestation who is expecting twins
ANS: D Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this patient's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
17. Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.
ANS: D A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.
18. Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the patient for epidural administration as ordered by the physician
ANS: D The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.
21. An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks' gestation and has two other children at home, ages 3 and 6. The patient's husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal? a. The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient's next scheduled antepartum visit the following week. b. The patient and husband will hire a nanny to act as an additional caregiver for the next month. c. The patient will continue to take care of her children at home, taking frequent rest periods. d. The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.
ANS: D A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified timeframe. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the patient to take care of her children at home with rest period because the patient will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.
16. Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure
ANS: D All assessments are important; however, those most relevant to tocolytic therapy include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication.
35. A pregnant woman develops hypertension. The nurse monitors the patient's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow
ANS: D Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.
26. Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at station
ANS: D If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.
10. A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "Let me take off the monitor belts and help you get into a more comfortable position." c. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
ANS: D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation.
11. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.
ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete.