U World Labor and Delivery Questions
The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education? 1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." 2. "I will establish a second IV line with an 18 gauge catheter." 3. "I will initiate serial blood pressure monitoring every 3-5 minutes." 4. "I will notify anesthesia and operating room staff of the client's condition immediately."
1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Uterotonic medications (oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion. After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding. Options 2, 3, and 4 are all appropriate interventions.
A nurse is preparing to administer an oxytocin IV infusion for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply. 1. Abnormal or indeterminate FHR patterns 2. Delayed breast milk production 3. Placenta previa 4. Postpartum hemorrhage 5. Uterine tachysystole
1. Abnormal or indeterminate FHR patterns 4. Postpartum hemorrhage 5. Uterine tachysystole Potential adverse effects of oxytocin include -Late decelerations, bradycardia -Emergency cesarean birth -Postpartum hemorrhage -Water intoxication -Uterine tachysytole
A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. The client is experiencing late decelerations. Which of the following interventions should the nurse implement? Select all that apply. 1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 3. Prepare for amnioinfusion 4. Reposition the client to supine 5. Stop the oxytocin infusion
1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 5. Stop the oxytocin infusion Late decelerations occur when fetal oxygenation is compromised (uteroplacental insufficiency, uterine tachysystole, hypotension). Immediate steps to correct late decelerations include: -Stopping oxytocin if it is being administered -Repositioning the client to the left/right side -Administering oxygen by face mask -Administering an IV bolus of isotonic fluid PRN If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery.
A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift
1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 4. Initiating IV magnesium sulfate Preterm labor is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: -Administering IM antenatal glucocorticoids (betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development -Administering antibiotics (penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs -Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation -Giving tocolytic medications to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect
A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. Collection of a clean-catch urine specimen 4. Vaginal examination to assess cervical dilation
1. Administration of prophylactic antibiotics Group B Streptococcus (GBS) can be transmitted to the newborn during labor and birth, resulting in serious complications. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for >18 hours, maternal temp is >100.4, or gestation is <37 weeks.
A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia
1. Applying counterpressure to the client's sacrum during contractions Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." The nurse can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, hell of the hand, or other firm object. Clients should be encouraged to change positions frequently during labor. Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning. Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time.
A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation
1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation Seizures are a potential complication of worsening preeclampsia, aka eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside. Deep tendon reflexes should be assessed hourly during administration as magnesium sulfate is a CNS depressant. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available. Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room.
A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 2. Firm and posterior cervix 3. History of precipitous labor 4. Reactive nonstress test
1. Bishop score of 10 The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score >6-8 usually indicates that induction will be successful.
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions 4. Painful, strong contractions every 3-4 minutes
1. Cessation of contractions and maternal tachycardia Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. The first sign of uterine rupture is usually abnormal fetal heart rate patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions.
The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale 2. Document that the client appears to be experiencing minimal pain 3. Monitor for nonverbal signs of ineffective coping with labor 4. Recognize that the client's stoicism is ineffective coping with labor
1. Complete hourly pain assessments using a numeric pain scale Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. So, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping. Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. Pain assessments using a numeric pain scale do not adequately assess coping during labor. Stoicism and lack of outward expressions of pain do not indicate that the client is not experiencing pain, nor should they be misidentified as ineffective coping.
A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply. 1. Contractions that increase in frequency 2. Contractions that lessen after resting 3. Increased blood-tinged, mucoid vaginal discharge 4. Pain in the lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation
1. Contractions that increase in frequency 4. Pain in the lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation A key indicator of true labor is the progressive effacement and dilation of the cervix. Contractions in true labor are regular, and increase in frequency, duration, and intensity. The pain may initially start in the lower back and radiate to the abdomen. Braxton Hicks contractions will typically lessen with comfort measures. Mucoid vaginal discharge that is blood-tinged or brownish is a common finding in the days preceding onset of labor, however, is not a definitive sign that true labor has started.
A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push x 1 is prescribed by the HCP. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.
1.2 mL
A pregnant client is brought to the ED by ambulance after her water broke. She is screaming and bearing down with every contraction. Which of the following assessment questions are essential to ask in preparation for the birth and possible newborn resuscitation? Select all that apply. 1. "Did you receive the influenza vaccine during pregnancy?" 2. "Do you take any medications or illicit drugs?" 3. "How many babies are you expecting?" 4. "What color was the fluid when your water broke?" 5. "When is your due date?"
2. "Do you take any medications or illicit drugs?" 3. "How many babies are you expecting?" 4. "What color was the fluid when your water broke?" 5. "When is your due date?" When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief, focused history to elicit essential information relevant to potential newborn resuscitation, including: -Recent medication or illicit drug use -Current pregnancy diagnoses (multiple gestation, placenta previa) -Color of the amniotic fluid -Expected due date (EDD) or estimated gestational age
A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probably cause of the change in fetal heart rate, which action should be taken first? 1. Administer IV fluid bolus 2. Assess for umbilical cord prolapse 3. Notify the health care provider 4. Reposition client to alternate side
2. Assess for umbilical cord prolapse Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord. Although IV fluid bolus is part of intrauterine resuscitation, in the presence of prolonged deceleration after rupture of membranes, the first action is to rule out a prolapsed cord. Someone else should notify the HCP while the nurse performs emergent interventions. A position change to the alternate side may help improve uteroplacental blood flow but will probably not displace the presenting part off a prolapsed cord
The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech 2. Document fetal presentation as cephalic 3. Elevate the fetal presenting part away from the prolapsed cord 4. Request that the health care provider confirm fetal presentation
2. Document fetal presentation as cephalic The nurse is most likely palpating the diamond-shaped anterior fontanels of the fetal head, which is in cephalic presentation. Therefore, the nurse should document the fetal presentation as such. With breech presentation, the fetal buttocks, legs, or feet may be palpated. A prolapsed cord would feel soft and rubbery on palpation and may be pulsating. Palpating the anterior fontanels should reassure the nurse that the fetus is in a good presentation, so there is no indication for informing the HCP.
A nurse is participating in an obstetrical emergency simulation in which the HCP announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1. Assist maternal pushing efforts by applying fundal pressure during each contraction 2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 4. Prepare for a forceps-assisted birth 5. Request additional assistance from other nurses immediately
2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 5. Request additional assistance from other nurses immediately Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. When should dystocia occurs, the primary nursing interventions include documenting the exact time of events, verbalizing passing time to guide decision-making by the HCP, performing maneuvers to relieve should impaction, and requesting for additional help. Fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications in the newborn.
A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication 2. Give the medication slowly during the peak of the next contraction 3. Hold until contractions are occurring at least every 4 minutes for an hour 4. Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication
2. Give the medication slowly during the peak of the next contraction Administration of IV narcotics during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth. Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief. There is no reason to discontinue oxytocin prior to IV administration of pain medications. However, IV push medications should not be given through IV lines already infusing medication. It is inappropriate to withhold pain medication simply because the frequency of contractions is inadequate. Narcotics given by IV push may be diluted according to manufacturer directions so that they can be more easily pushed over the recommended administration interval, but diluent should never be obtained from the IV bag or tubing due to the risk of inadvertently adding medication to IV fluids.
The nurse is verifying the medical history of a client who is admitted for a scheduled labor induction. Which client statement should prompt the nurse to request further evaluation for a primary cesarean birth from the HCP? 1. "A vacuum was used to help deliver my last baby because the baby's heart rate was dropping." 2. "I have an atrial septal defect that has never given me any problems, and I plan to receive an epidural during labor." 3. "I lost my acyclovir prescription, and I've noticed lesions on my labia that are stinging and burning." 4. "I took enoxaparin during this pregnancy due to a history of blood clots, and my last dose was yesterday."
3. "I lost my acyclovir prescription, and I've noticed lesions on my labia that are stinging and burning." Genital herpes, an incurable STI caused by herpes simplex virus, is characterized by painful, vesicular lesions that form ulcers that crust over. Clients with a history of genital herpes are prescribe antivirals around 36 weeks gestation to prevent outbreaks prior to labor. Clients with active genital herpes infections or prodromal symptoms (pain, burning, tingling) require a cesarean birth to prevent transmission to the fetus.
The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client? 1. Apply tocodynamometer and evaluate current contraction pattern 2. Ask the client about the family's desire for speaking with a chaplain 3. Draw coagulation tests, fibrinogen, and CBC with PLTs 4. Initiate oxytocin prescription to begin induction of labor
3. Draw coagulation tests, fibrinogen, and CBC with PLTs Clients with intrauterine fetal demise are at risk for DIC. Baseline lab tests and physical assessment for signs of DIC area priority for at-risk clients because clotting and bleeding are often sudden and life-threatening. DIC can progress quickly, so it is important to perform this intervention to prevent life threatening external and internal bleeding.
The nurse reviews the laboratory results of a laboring client who is requesting epidural anesthesia. Which value is the priority to report to the anesthesia provider prior to epidural placement? 1. O blood type and negative Rh factor 2. Hemoglobin of 10 g/dL 3. Platelet of 90,000/mm3 4. WBCs of 15,000/mm3
3. Platelet of 90,000/mm3 Epidural anesthesia, an elective procedure for pain relief in labor, may be contraindicated in clients with uncorrected hypotension, coagulopathies, or infection at the epidural site. Low platelets in pregnancy may occur as part of HELLP syndrome. Clients with low platelets are at risk for bleeding at the epidural puncture site, which may lead to hematoma formation, spinal cord compression, and subsequent neurologic dysfunction. Options 1, 2, and 4 are all normal lab values in a pregnant woman.
Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use 2. Multipara at 9 cm dilation with an urge to push 3. Nullipara at 3 cm dilation desiring to ambulate 4. Nullipara at 7 cm dilation moaning with contractions
4. Nullipara at 7 cm dilation moaning with contractions IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well established contraction pattern because opioid administration may slow labor progression in the latent phase. Recent heroin use is a contraindication to opioid agonist-antagonists d/t risk of withdrawal symptoms in the mother and/or fetus. An urge to push may indicate imminent birth, especially in a multiparous client, which is a relative contraindication for the administration of narcotics. Opioid administration in latent labor may slow labor progression.
A client in labor has reached 8 cam dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? 1. Administer prescribed IV meperidine for pain relief 2. Encourage client to bear down with spontaneous urges to push 3. Place client in the lithotomy position in preparation for birth 4. Provide encouragement and coaching in breathing techniques
4. Provide encouragement and coaching in breathing techniques The period of active labor from 8-10 cm dilation ("transition") is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed during transition. Nursing priorities include providing emotional support and encouragement, and coaching the client in breathing techniques. Meperidine is an opioid occasionally prescribed for analgesia during early labor. It should be avoided within 1-2 hours of birth d/t the potential for neonatal respiratory depression. Pushing should be delayed until complete dilation is achieved to avoid cervical swelling and/or cervical lacerations. Although lithotomy positioning may be more convenient for the birth attendant, upright or lateral positions encourage fetal rotation and descent, increase client comfort, and decrease the risk of perineal trauma.
A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block
4. Pudendal nerve block A pudendal nerve block infiltrate local anesthesia (lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the HCP. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor. An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. IV narcotics bc they can cause neonatal respiratory depression are not generally administered in the second stage of labor.
The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain? 1. The client has a history of three previous cesarean births 2. The client has a signed consent form for a cesarean hysterectomy 3. The client has removed all metal jewelry and contact lenses 4. The client has two 18-gauge IVs and a blood type and crossmatch
4. The client has two 18-gauge IVs and a blood type and crossmatch Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. The major complication of placenta accreta is life threatening hemorrhage, which occurs during attempted placental separation. At least 2 large-bore IVs (18G) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary. Knowing the client's medical/surgical history is important but is not prioritized over the client's readiness for a blood transfusion. The client should understand the implications of the procedure, but checking for a signed consent is not a priority over ensuring readiness for a potential blood transfusion. Metal and occasionally contact lenses should be removed prior to surgery to protect the client from injury, but it is again not a priority.
A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma
4. Vaginal hematoma A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly.
What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted 2. Provide information to the parents about genetic counseling 3. Refer the parents to a perinatal loss support groups 4. Wrap the newborn in warm blankets for the parents to hold
4. Wrap the newborn in warm blankets for the parents to hold Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are not compatible with life. Comfort care for the newborn and emotional support for the family is priority at the time of birth.