Course Point Chapter 21

A birth room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48 mm Hg, pulse rate 150 bpm, and mucous membranes are pale. Which interventions should be the priority for the nurse? Select all that apply.

Apply oxygen mask at 10 L/min. Discontinue the IV oxytocin infusion.

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply.

CBC U/A amniotic fluid analysis

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?

Depressed deep tendon reflexes

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?

erratic

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple.

When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications?

Be sure to monitor fetal movements daily.

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?

Look for late decelerations on monitor, which is associated with fetal anoxia.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRoberts maneuver

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

Occiput posterior position

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?

Placental abruption

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

Second stage of labor

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?

has previous lower abdominal incision

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical

A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply.

low socioeconomic status smoking high level of stress alcohol use

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation

A G3, P2 woman arrives at the birthing center stating that she has been in labor for the past 18 hours. To rule out a potential protracted disorder the nurse is aware that which criterion for cervical dilation would be used?

1.5 cm per hour

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:

4,000 g or more.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor.

The nurse is monitoring a woman who is receiving oxytocin IV to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?

Discontinue the oxytocin infusion.

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time?

Offer to take pictures and footprints of the infant once it is delivered.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

Use McRoberts maneuver.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

Uterine rupture

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks.

A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? Select all that apply.

cyanosis pulmonary edema

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply.

history of previous preterm birth current multiple gestation pregnancy uterine or cervical abnormalities

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?

Late decelerations

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?

Leopold's maneuver

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?

McRoberts maneuver

A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question?

More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

A woman has been progressing through labor uneventfully until following an intense contraction, when she develops signs of umbilical cord compression. The primary care provider can feel a portion of the cord in the vagina. Which emergency intervention should the nurse implement? Select all that apply.

Place a gloved hand in vagina, put upward pressure on presenting part to keep it off the cord. Position the woman in a knee-chest position. Apply oxygen mask at 10 L/min. Administer terbutaline, a tocolytic, as prescribed.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum

A client in her 42nd week of pregnancy is undergoing a scheduled induction of labor based on consideration of which factors? Select all that apply.

cervical ripeness fetal size gestational age

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?

complications of a postterm pregnancy

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:

place a hand gently on the fetal head to guide birth.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding.

Before calling the primary care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder.

The nursing student demonstrates an understanding of dystocia with which statement?

Dystocia is diagnosed after labor has progressed for a time.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin

A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is post-term and has oligohydramnios. What does this increase the risk of during birth?

cord compression

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule?

Cervix dilates 1 cm per hour.

At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?

Hospitalization, tocolytic, and corticosteroids

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?

amniotic fluid embolism

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

contractions most forceful in the middle of uterus rather than the fundus

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor

12s A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate?

providing a comfortable environment with dim lighting

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours

The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery?

Abnormal position of the fetal head

The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?

Experience of additional back pain

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?

Prepare to assist with external version.

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?

tocolytic therapy

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?

A full bladder or rectum can impede fetal descent.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

Fetal heart tones

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?

Keep the communication lines open.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

magnesium sulfate

A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

uterine rupture