Chapter 10 High-Risk Labor And Birth

Vacuum extractor cup placement on the fetal head should not exceed: A. 5 minutes B. 10 minutes C. 20 minutes D. 30 minutes

C. 20 minutes

The benefits of VBACs include: A. Shorter recovery time, fewer infections, decreased blood loss B. Decreased pain, decreased fetal stress C. Shorter recovery time, decreased fetal stress D. Decreased discomfort, decreased anxiety

A. Shorter recovery time, fewer infections, decreased blood loss

A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations should the nurse advise the patient that her request may be declined? A. Transverse fetal lie B. Flexed fetal attitude C. Previous low flap uterine incision D. Positive vaginal candidiasis

ANS: A A baby in the transverse lie is lying sideways in the uterus. This lie is incompatible physiologically with a vaginal delivery.

Your patient is a 28-year-old gravida 2 para 1 in active labor. She has been in labor for 12 hours. Upon further assessment, the nurse determines that she is experiencing a hypotonic labor pattern. Possible maternal and fetal implications from hypotonic labor patterns are: A. Intrauterine infection and maternal exhaustion with fetal distress usually occurring early in labor. B. Intrauterine infection and maternal exhaustion with fetal distress usually occurring late in labor. C. Intrauterine infection and postpartum hemorrhage with fetal distress early in labor. D. Intrauterine infection and ruptured uterus and fetal death.

ANS: B Hypotonic labor patterns increase risk for infection and maternal exhaustion, with fetal distress occurring late in labor as hypotonic patterns prolong labor.

A primigravida woman at 42 weeks' gestation received Prepidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which of the following actions by the nurse is appropriate? A. Perform Nitrazine analysis of the amniotic fluid. B. Report the lack of progress to the obstetrician. C. Place the woman on her left side. D. Ask the doctor for an order for oxytocin.

ANS: B Little progress has taken place. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective.

The perinatal nurse understands that the most appropriate nursing action following an amniotomy is an assessment of the __________ as well as the __________ and __________ of the amniotic fluid.

ANS: fetal heart rate; color; odor The nurse carefully monitors the patient who will undergo an amniotomy. Vital signs, cervical effacement and dilation, station of the presenting part, fetal heart rate, and color and amount of amniotic fluid are assessed.

The perinatal nurse prepares for two potential complications that may accompany a precipitous labor and birth: postpartum __________ and a need for neonatal __________.

ANS: hemorrhage; resuscitation

The perinatal nurse caring for a laboring woman who is receiving an oxytocin infusion documents the following information: rate of __________, frequency and strength of __________, fetal __________, and cervical __________ and __________.

ANS: infusion; contractions; heart rate; dilatation; effacement Oxytocin protocols in many institutions require that the nurse remain at the patient's bedside at all times for careful surveillance. The following data should be placed on a flow sheet in the patient record: patient's vital signs, fetal heart rate, frequency, duration and strength of contractions, cervical effacement and dilatation, fetal station and lie, rate of oxytocin infusion intake and urine output, and the psychological response of the patient.

The perinatal nurse recognizes that the laboring multiparous patient who is attempting a vaginal birth following a previous cesarean birth (VBAC) needs frequent assessments to ensure that there is __________ during her labor.

ANS: progress Women with a previous history of cesarean birth may be offered a trial of labor, although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise.

A high probability of successful induction is associated with a Bishop score of: A. Greater than 4 B. Greater than 6 C. Less than 4 D. Less than 6

B. Greater than 6

An increased risk for shoulder dystocia is associated with: A. Preterm labor B. Maternal diabetes C. VBAC D. Previous precipitous birth

B. Maternal diabetes

Preeclampsia, thrombosis, gestational and type II diabetes are associated risk factors for what? A. Good nutrition B. Maternal obesity C. Cardiac problems D. Maternal weight

B. Maternal obesity

Which nursing action can improve uterine blood flow, increase umbilical cord circulation, improve maternal oxygenation, and decrease uterine activity? A. Administering oxygen to the mother B. Changing the woman's position C. Discontinuing oxytocin D. Infusing intravenous fluids

C. Discontinuing oxytocin

The first sign of shoulder dystocia is referred to as: A. Unsuccessful vaginal delivery B. Breech C. Bishop Score D. Turtle sign

D. Turtle sign

A laboring woman reports spontaneous rupture of membranes and you assess severe decelerations in the FHR. Examination reveals a cord in the vagina. The first nursing action is to: A. Manually elevate the presenting part B. Administer a tocolytic agent C. Administer an IV fluid bolus D. Empty the patient's bladder

A. Manually elevate the presenting part

Four women are close to delivery on the labor and delivery unit. The nurse knows to be vigilant to the signs of neonatal respiratory distress in which delivery? A. 42-week-gestation pregnancy complicated by intrauterine growth restriction B. 41-week-gestation pregnancy with biophysical profile score of 10 that morning C. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams D. 39-week-gestation pregnancy complicated by maternal cholecystitis

ANS: A A post-term baby with intrauterine growth restriction (IUGR) is high risk for meconium aspiration syndrome, cold stress syndrome, hypoglycemia, and acidosis. In each case, the baby may exhibit signs of respiratory distress.

Augmentation of labor: A. Is part of the active management of labor instituted when the labor process is unsatisfactory and uterine contractions are inadequate B. Relies on more invasive methods when oxytocin and amniotomy have failed C. Is elective induction of labor D. Is an operative vaginal delivery that uses vacuum cups

ANS: A Augmentation stimulates uterine contractions after labor has started but not progressed appropriately.

During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurse's most appropriate action is to notify the physician/certified nurse midwife and describe a: A. Need for vaginal assessment and repair B. Requirement for an oxytocin infusion C. Need for further information for the woman/family about forceps D. Requirement for bladder assessment and catheterization

ANS: A In the presence of a firm fundus and bright red bleeding, after a forceps-assisted birth there is a need for vaginal assessment and there may be a need for repair.

The perinatal nurse notes a rapid decrease in the fetal heart rate that does not recover immediately following an amniotomy. The most likely cause of this obstetrical emergency is: A. Prolapsed umbilical cord B. Vasa previa C. Oligohydramnios D. Placental abruption

ANS: A The nurse needs to assess the fetal heart rate immediately before and after the artificial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such as bradycardia and variable decelerations may be indicative of cord compression or prolapse.

The physician has ordered intravenous oxytocin for induction for four gravidas. In which of the following situations should the nurse refuse to comply with the order? A. Primigravida with complete placenta previa B. Multigravida with extrinsic asthma C. Primigravida who is 38 years old D. Multigravida who is colonized with group B streptococci

ANS: A The nurse should refuse to comply with this order because labor is contraindicated for a patient with complete placenta previa. This patient will have to be delivered via cesarean section.

The nurse is assisting a physician in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? A. Risk for injury B. Colonic constipation C. Risk for impaired parenting D. Ineffective individual coping

ANS: A There is a risk for injury. For example, the patient could suffer a cervical, vaginal, or perineal laceration.

Documentation related to vacuum delivery includes which of the following: (Select all that apply) A. Fetal heart rate B. Timing and number of applications C. Position and station of fetal head D. Maternal position

ANS: A, B, C Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

Hyperstimulation is defined as: (Select all that apply) A. Contractions lasting more than 2 minutes B. Five or more contractions in 10 minutes C. Contractions occurring within 1 minute of each other D. Uterine resting tone below 20 mm/Hg

ANS: A, B, C Contractions lasting more than 2 minutes, five or more contractions in 10 minutes, and contractions occurring within 1 minute of each other describe the criteria for hyperstimulation. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone.

Contraindications for induction of labor include: (Select all that apply) A. Abnormal fetal position B. Postdated pregnancy C. Pregnancy-induced hypertension D. Placental abnormalities

ANS: A,D Contraindications for induction of labor include abnormal fetal position because of the risk of fetal injury and placental abnormalities because of the risk of hemorrhage. Pregnancy-induced hypertension and post term pregnancy are two of the common indications for induction of labor.

The perinatal nurse includes the following when explaining the physiology of artificial rupture of membranes to the student nurse: rupture of membranes causes a release of arachidonic acid, which converts to prostaglandins, substances known to stimulate oxytocin in the pregnant uterus. A. True B. False

ANS: A. True At certain points in the labor, an amniotomy, or artificial rupture of the membranes, may be successful in increasing uterine contractility.

The perinatal nurse describes asynclitism to students as a presentation that occurs when the fetal head is turned toward the maternal sacrum or symphysis at an oblique angle. A. True B. False

ANS: A. True Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part. These presentations are uncommon and are usually associated with fetal anomalies.

You are caring for a primiparous woman admitted to labor and delivery for induction of labor at 42 weeks' gestation. She asks you to explain the factors that contribute to prolonged labor and dystocia. The best response would be to state the following: A. Primiparous women are not at risk for dystocia because they usually have small babies. B. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of the mother, and psychosocial response. C. Labor is primarily associated with pelvic abnormalities. D. Dystocia is typically diagnosed prior to labor based on pelvimetry.

ANS: B This is the only correct definition of prolonged labor and dystocia. The success of any labor depends on the complex interrelationship of several factors: fetal size, presentation, position, size and shape of the pelvis, and quality of uterine contractions.

The perinatal nurse explains to the student nurse that the most frequent fetal risk associated with the use of forceps is cord compression. A. True B. False

ANS: B. False The most frequent fetal risk associated with the use of forceps is superficial scalp or facial marks that will resolve quickly.

What is contraindicated with shoulder dystocia? A. Vaginal Birth B. Fundal pressure C. Cervical checks D. Vaginal exams

ANS: B. Fundal pressure Fundal pressure is contraindicated with shoulder dystocia because it may further impact the shoulder and increases risk of fetal injury.

During labor, oxytocin is always administered via what route? A. IM B. IV C. Orally D. Rectally

ANS: B. IV During labor, oxytocin can only be administered intravenously via an infusion pump to titrate and regulate the dose for safe administration.

The perinatal nurse is providing care to Carol, a 28-year-old multiparous woman in labor. Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as "strong." Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling some rectal pressure. Carol is most likely experiencing: A. Hypertonic contractions B. Hypotonic contractions C. Precipitous labor D. Uterine hyperstimulation

ANS: C Contrary to both hypertonic and hypotonic labor, precipitate labor contractions produce very rapid, intense contractions. A precipitous labor lasts less than 3 hours from the beginning of contractions to birth. Patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor.

During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2 minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action? A. Increase oxytocin infusion rate per physician's protocol. B. Stop oxytocin infusion immediately. C. Maintain present oxytocin infusion rate and continue to assess. D. Decrease oxytocin infusion rate by 2 mU/min and report to physician.

ANS: C Maintain present oxytocin infusion rate and continue to assess is the correct response, as this question describes a normal uterine contraction pattern.

If the umbilical cord prolapses during labor, the nurse should immediately: A. Type and cross-match blood for an emergency transfusion. B. Await MD order for preparation for an emergency cesarean section. C. Attempt to reposition the cord above the presenting part. D. Apply manual pressure to the presenting part to relieve pressure on the cord.

ANS: D Apply manual pressure to the presenting part to relieve pressure on the cord represents the first nursing intervention to attempt to improve circulation to the fetus.

A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4, fetal heart rate 140s with good variability and no decelerations, T 98.6ºF, P 88, RR 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? A. Bishop score of 5 B. Fetal heart of 152 bpm C. Respiratory rate of 24 rpm D. Contraction frequency of every 2 minutes

ANS: D Cervidil should be removed for tachysystole.

When fetal vessels are unsupported by placenta or the umbilical cord traverses the membranes over the cervix, below the presenting part, this is referred to as: A. Anterior dystocia B. Vasa Previa C. Breech D. Placenta Previa

B. Vasa Previa

Women 40 years or older have a cesarean rate of: A. 25.5% B. 62.5% C. 35.5% D. 49.5%

D. 49.5%