Chapter 21 prepu
The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider? hematocrit of 36% 45 ml urine output in 2 hours hemoglobin of 13 g/dl platelet count of 150,000 mm3
Correct response: 45 ml urine output in 2 hours Explanation: The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.
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 in a 20 cc bolus of saline. Administer oxytocin in two divided intramuscular sites. Administer oxytocin diluted in the main intravenous fluid. Administer oxytocin diluted as a "piggyback" infusion.
Correct response: Administer oxytocin diluted as a "piggyback" infusion. Explanation: Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.
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 thyroid level arterial blood gases
Correct response: CBC U/A amniotic fluid analysis Explanation: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.
36-48%
normal hct for women is
The nursing student demonstrates an understanding of dystocia with which statement? "Dystocia is diagnosed at the start of labor." "Dystocia is not diagnosed until after the birth." "Dystocia is diagnosed after labor has progressed for a time." "Dystocia cannot be diagnosed until just before birth."
Correct response: "Dystocia is diagnosed after labor has progressed for a time." Explanation: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: 5. 6. 7. 9.
Correct response: 5. Explanation: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.
Before calling the health 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 health care provider? Make sure the epidural medication is turned down. Check for a full bladder. Make sure the client is lying on her left side. Assess vital signs every 30 minutes.
Correct response: Check for a full bladder. Explanation: A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.
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? Bed rest and hydration at home Hospitalization, tocolytic, and corticosteroids An emergency cesarean birth Careful monitoring of fetal kick counts
Correct response: Hospitalization, tocolytic, and corticosteroids Explanation: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring in a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.
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 preterm birth nullipara pendulous abdomen
Correct response: diabetes Explanation: Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.
The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which statements should she include in her presentation? Select all that apply. It significantly increases the risk of cesarean birth. It significantly increases the weight of the newborn. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU.
Correct response: It significantly increases the risk of cesarean birth. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. Explanation: Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented birth, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor.
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? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).
Correct response: Look for late decelerations on monitor, which is associated with fetal anoxia. Explanation: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.
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? McDonald maneuver McGeorge maneuver McRoberts maneuver McRonald maneuver
Correct response: McRoberts maneuver Explanation: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.
A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? Low potassium or elevated glucose, tachycardia, chest pain Respiratory depression, hypotension, absent tendon reflexes Severe lower back pain, leg cramps, sweating Pain in the abdomen, shoulder, or back
Correct response: Respiratory depression, hypotension, absent tendon reflexes Explanation: Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other options are incorrect indications of magnesium sulfate toxicity.
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? Slow the oxytocin infusion to the initial rate. Continue to monitor contractions and fetal heart rate. Stop the infusion immediately. Notify the birth attendant.
Correct response: Stop the infusion immediately. Explanation: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? Increase the oxytocin. Turn off the oxytocin. Increase the methotrexate. Turn off the methotrexate.
Correct response: Turn off the oxytocin. Explanation: Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.
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? placental separation aspiration amniotic fluid embolism congestive heart failure
Correct response: amniotic fluid embolism Explanation: With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? cervical lacerations perineal hematoma infection of episiotomy caput succedaneum
Correct response: caput succedaneum Explanation: Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps-assisted birth. Maternal complications include tissue trauma such as lacerations of the cervix, vagina, and perineum; hematoma; extension of episiotomy into the anus; hemorrhage; and infection.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? applying suprapubic pressure against the fetal back continuing to monitor maternal and fetal status noting the space at the maternal umbilicus auscultating the fetal heart rate at the level of the umbilicus
Correct response: continuing to monitor maternal and fetal status Explanation: Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.
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 hypertonic contractions uncoordinated contractions Braxton Hicks contractions
Correct response: hypotonic contractions Explanation: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: longer length of labor. increased number of overall pregnancies. increasing birth weight. poor quality of prenatal care.
Correct response: increasing birth weight. Explanation: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.
A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? betamethasone magnesium sulfate indomethacin nifedipine
Correct response: magnesium sulfate Explanation: The drug used to relax the uterine muscles and for seizure prophylaxis is magnesium sulfate. Betamethasone promotes fetal lung maturity, indomethacin inhibits uterine activity to arrest preterm labor, and nifedipine blocks calcium movement into the muscle cells and inhibits preterm labor.
After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? reports of severe back pain lack of cervical dilation past 2 cm fetal buttocks as the presenting part contractions most forceful in the middle of uterus rather than the fundus
Correct response: reports of severe back pain Explanation: Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.
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? bronchodilators tocolytic therapy muscle relaxants anti-anxiety therapy
Correct response: tocolytic therapy Explanation: Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity.
