vaginal delivery NUr2261
The nurse is caring for a primigravida at 41 weeks' gestation. The patient is being induced for oligohydramnios and is now 5 cm dilated and 0 station. Which condition may require the patient to need a cesarean birth?
A. Category III FHR tracing A. Category III FHR tracing B. Category I FHR tracing C. Rupture of membranes more than 24 hours ago D. Bloody show noted with dilation Rationale: Complications of labor that may indicate the need for cesarean delivery include, in order of frequency, labor dystocia, Category II (indeterminate) FHR tracing characteristics or Category III (abnormal) FHR tracing characteristics, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. A Category I FHR tracing is normal and would not be a reason to need a cesarean birth. Rupture of membranes more than 24 hours ago increases the risk for infection but is not an indication for a cesarean birth. Bloody show is a normal finding as the patient progresses in labor.
The nurse is caring for a primigravida at 40 weeks' gestation in the second stage of labor. The patient does not have an epidural and is experiencing an urge to push. The nurse knows the pressure of the presenting part on the patient's rectum and pelvic floor causes an involuntary pushing response. What is the name of this response?
A. Ferguson reflex A. Ferguson reflex B. Turtle sign C. Chadwick sign D. "Laboring down" Rationale: As the fetus descends, pressure of the presenting part on the patient's pelvic floor stretch receptors causes an involuntary pushing response called the Ferguson reflex. The turtle sign occurs when the head, appearing on the perineum (crowning), retracts against the perineum immediately following its emergence. The Chadwick sign is a bluish discoloration of the cervix, vagina, and labia caused by increased blood flow in early pregnancy. Laboring down allows for passive descent of the fetus and rotation to an anterior position until the presenting part is low enough to stimulate the Ferguson reflex
In which stage of labor does pushing occur?
A. Second stage A. Second stage B. Third stage C. Fourth stage D. Last stage Rationale: The second stage (expulsion) begins with complete dilation of the cervix and ends with the birth of the newborn; in this stage, the patient begins pushing. The first stage of labor begins with regular uterine contractions and is complete when the cervix is fully dilated (10 cm). The third stage begins once the newborn has been delivered and is completed with the delivery of the placenta. The fourth stage of labor occurs immediately after the delivery of the placenta and includes at least the first 2 hours after delivery. The last stage is not a name for a stage of labor.
Immediately after the patient delivers the placenta, which drug may the practitioner order?
B. Oxytocin A. Potassium chloride B. Oxytocin C. Dinoprostone D. Methylergonovine Rationale: Atony (the inability of the uterus to contract) may occur after delivery as a result of the uterus having been overworked; atony may lead to hemorrhage, so the practitioner may consider administering oxytocin prophylactically immediately after delivery of the placenta to help the uterus contract and to prevent hemorrhage. Potassium chloride is an electrolyte, which is not indicated following delivery of the placenta. Dinoprostone is a cervical ripening agent. Methylergonovine is the next substance that may be used if atony persists; however, it is contraindicated in patients with hypertension.
A patient at term presents to the triage area with contractions. During this pregnancy, the patient has had minimal prenatal care. What finding would indicate the need for a cesarean birth?
B. Transverse presentation A. Category I FHR tracing B. Transverse presentation C. Singleton pregnancy D. Preeclampsia Rationale: A transverse presentation is an indication for a cesarean birth because it is a fetal malpresentation—the shoulder is the presenting part. The fetus is lying horizontally across the uterus and a vaginal delivery is contraindicated. A Category I FHR tracing is considered normal and does not indicate the need for a cesarean birth. A singleton pregnancy and preeclampsia do not automatically indicate the need for a cesarean birth.
In preparation for a vaginal delivery of a patient at term, the nurse has set up the delivery table with instruments and checked the infant warmer for suction and resuscitation equipment. What health care team members should be present at every delivery in order to adequately care for the newborn?
C. At least one health care team member capable of performing the initial steps of newborn resuscitation and PPV A. A pediatrician, a pediatric nurse, and a respiratory therapist B. A neonatal nurse practitioner and a respiratory therapist C. At least one health care team member capable of performing the initial steps of newborn resuscitation and PPV D. A neonatologist, a neonatal intensive care unit nurse, and a respiratory therapist Rationale: At least one health care team member capable of performing the initial steps of newborn resuscitation and PPV should attend every delivery. It is not necessary to have a pediatrician, neonatologist, neonatal nurse practitioner, pediatric nurse, neonatal intensive care unit nurse, or respiratory therapist present unless circumstances indicate a need for their presence.
A routine vaginal delivery is underway. How should the nurse assist the patient with pushing?
C. Encourage the patient to push when feeling an urge to push. A. Tell the patient to "Push," "Push," "Push," during contractions. B. Have the patient push to the count of 10 with contractions. C. Encourage the patient to push when feeling an urge to push. D. Have the support person direct the patient's pushing efforts. Rationale: The nurse should encourage the patient to push when feeling an urge to push (spontaneous pushing) rather than give a prolonged push on command. The patient may become confused and anxious when being told to do something in conflict with what the body is saying. Having the patient push to the count of 10 will interfere with placental and fetal oxygenation if the patient holds the breath too long. Neither the nurse nor the support person should tell the patient to "Push," "Push," "Push," because doing so would interfere with the patient's natural pushing instincts.
The nurse is caring for a laboring multigravida at 39 weeks' gestation. The patient received an epidural 2 hours ago and is now ready for delivery. The nurse determines that the patient's bladder is filling. What is the most appropriate action by the nurse?
C. Perform a straight catheterization before delivery. A. Place an indwelling catheter before delivery. B. Have the patient void on a bedpan before delivery. C. Perform a straight catheterization before delivery. D. Catheterize the patient after delivery. Rationale: Straight catheterization should be performed before delivery if a labor patient has a regional anesthetic and the bladder is distended. The use of indwelling catheters should be avoided whenever possible in labor. If left in place during delivery, the inflated bulb of the indwelling catheter can cause damage to the urethra. A laboring patient with an epidural is frequently not able to void on a bedpan or empty the bladder completely. If the patient's bladder is distended, the bladder should be catheterized before, not after, delivery to avoid soft-tissue obstruction, which will interfere with fetal descent.
The nurse is caring for a patient who is at 40 weeks' gestation and has a history of gestational diabetes. At delivery, the turtle sign is noted. For which condition should the nurse prepare?
C. Shoulder dystocia A. Perineal laceration B. Postpartum hemorrhage C. Shoulder dystocia D. Cesarean delivery Rationale: The turtle sign means that the head, appearing on the perineum (crowning), retracts against the perineum immediately following its emergence; this sign indicates that shoulder dystocia may be present. The turtle sign is not a term used to describe postpartum hemorrhage, perineal laceration, or the need for a cesarean delivery.
The practitioner notes shoulder dystocia and asks the nurse to perform the McRoberts maneuver. Which action should the nurse take?
D. Flex the patient's thighs sharply against the abdomen. A. Lower the head of the bed to assist in delivering the shoulder. B. Push the fetal anterior shoulder downward. C. Apply fundal pressure. D. Flex the patient's thighs sharply against the abdomen. Rationale: The McRoberts maneuver is defined by sharp flexion of the patient's thighs against the abdomen, which somewhat straightens the pelvic curve. Pushing the fetal anterior shoulder downward displaces it from above the patient's symphysis pubis; this is accomplished by application of suprapubic pressure, not by flexing the thighs. Fundal pressure is downward pressure applied to the top of the uterus; it should not be used because it pushes the anterior shoulder even more firmly against the patient's symphysis pubis. Placing the head of the bed down is contraindicated in a case of shoulder dystocia because it restricts the pelvic outlet.
