Chapter 22: Complications Occurring During Labor and Delivery

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?

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.

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?

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 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?

Correct response: Offer to take pictures and footprints of the infant once it is delivered. Explanation: When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

Correct response: Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Explanation: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.

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?

Correct response: Uterine rupture Explanation: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

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

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 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?

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.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Correct response: fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds?

Correct response: high in the abdomen Explanation: With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.

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

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.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

Correct response: knee-chest Explanation: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?

Correct response: patent airway Explanation: Babies born after a face presentation have a great deal of facial edema and may be purple from ecchymotic bruising. The nurse must observe the infant closely for a patent airway. Arching of eyebrows is not a priority. Ability to swallow and palpation of the fontanels (fontanelles) are routine assessments for all newborns, but they are not the priority.

The fetus of a mother in active labor continues to have late decelerations with each contraction. The obstetric provider determines a cesarean birth is necessary. The nurse prepares the mother for the emergency surgery. When should the nurse stop external fetal monitoring?

Correct response: prior to the abdominal prep Explanation: If a client is already in labor when the decision is made to deliver by cesarean birth, monitoring continues into the operating room. If external fetal monitoring is being used, it continues until the preparation of the abdomen begins. Internal monitoring is discontinued just prior to the incision.

The nurse is assisting the mother to push. The nurse suspects shoulder dystocia is present when which symptom is present?

Correct response: turtle sign Explanation: Turtle sign is often the first indication of shoulder dystocia. With turtle sign the fetal head is born but the cheeks of the newborn rest on the maternal introitus as the anterior is unable to pass beneath the symphysis pubis. The fetal head remaining at 0 station is an indication of failure to descend. Continuous back pain is associated with an occiput posterior (OP) position. The battle sign is related to a head injury.

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

Correct response: "I know you are hurting, but you can have another baby in the future." Explanation: Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.

It is necessary for the mother to have a forceps delivery. To reduce complications from this procedure, the nurse should:

Correct response: empty the mother's bladder. Explanation: Forceps delivery may be outlet, low, or midforceps depending on the station of the fetus and the rotation of the fetal head. Client consent must be obtained and the maternal bladder must be emptied to reduce the chance of bladder injury and to increase the room for the fetus. The anesthesia provider and neonatologist would only be necessary if there was suspicion of complications to the mother and the fetus.

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?

Correct response: erratic. Explanation: Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.