Intrapartum NCLEX

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#35

A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A. 1 cm above the ischial spine B. 1 fingerbreadth below the symphysis pubis C. 1 inch below the coccyx D. 1 inch below the iliac crest

1 cm above the ischial spine Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines. Option B: The doctor will assign a number from -5 to +5 to describe where the baby is in relation to the ischial spines. The ischial spines are bony protrusions located in the narrowest part of the pelvis. During a vaginal exam, the doctor will feel for the baby's head. If the head is high and not yet engaged in the birth canal, it may float away from their fingers. Option C: When the baby's head is level with the ischial spines, the fetal station is zero. Once the baby's head fills the vaginal opening, just before birth, the fetal station is +5. Option D: Usually about two weeks before delivery, the baby will drop into the birth canal. This is called being "engaged." At this point, the baby is at station 0. This drop into the birth canal is called a lightening.

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A. Not yet engaged B. Entering the pelvic inlet C. Below the ischial spines D. Visible at the vaginal opening

Below the ischial spines A station of +1 indicates that the fetal head is 1 cm below the ischial spines. Positive numbers are used when a baby has descended beyond the ischial spines. During birth, a baby is at the +4 to +5 station. Option A: During a vaginal exam, the doctor will feel for the baby's head. If the head is high and not yet engaged in the birth canal, it may float away from their fingers. Option B: When the baby's head is level with the ischial spines, the fetal station is zero. Once the baby's head fills the vaginal opening, just before birth, the fetal station is +5. Option D: Usually about two weeks before delivery, the baby will drop into the birth canal. This is called being "engaged." At this point, the baby is at station 0. This drop into the birth canal is called a lightening.

A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? A. Hypotonic contractions B. Forceps delivery C. Schultz delivery D. Weak bearing down efforts

Forceps delivery. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall. Option A: Phelan et al found that abnormal patterns of uterine activity, such as tetany and hyperstimulation, are often not associated with uterine rupture. In their study, in which monitoring of uterine activity was limited to external tocodynamometry, tetany was defined as a contraction lasting longer than 90 seconds, and hyperstimulation was defined as more than 5 contractions in 10 minutes. Option C: The separation of the placenta from the uterine wall during labor; it begins at the placental center and leads to an expulsion of the placenta after delivery of the baby. Option D: Rodriguez et al found that the usefulness of intrauterine pressure catheters (IUPCs) for diagnosing uterine rupture was not supported. In 76 cases of uterine rupture, the classic description of decreased uterine tone and diminished uterine activity was not observed in any patients, 39 of whom had IUPCs in place. In addition, rates of fetal and maternal morbidity and mortality associated with uterine rupture did not differ with the use of an IUPC compared with external tocodynamometry.

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. Increased urinary output C. Adequate resting tone of the uterus palpated between contractions D. A fetal heart rate of 90 beats per minute

A fetal heart rate of 90 beats per minute A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue Pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period. Option A: Pitocin (oxytocin injection) is a natural hormone that causes the uterus to contract used to induce labor, strengthen labor contractions during childbirth, control bleeding after childbirth, or induce an abortion. Option B: Oxytocin has an antidiuretic effect and increases the urinary excretion of AQP2 in humans whose urinary concentration mechanism is preserved. Urine volume and free water clearance were decreased, and urine osmolality was increased by the administration of oxytocin or dDAVP in the normal volunteers and CDI patients. Option C: In a normal labor, one contraction every two to three minutes or less than five contractions in a 10 minute period is ideal. A uterus must rest between contractions, having sufficient uterine resting tone (soft to the touch), and uterine resting time (about one minute).

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A. An acceleration B. An early elevation C. A sonographic motion D. A tachycardia

An acceleration An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute. Option B: Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm. This pattern is sometimes called a saltatory pattern and is usually caused by acute hypoxia or mechanical compression of the umbilical cord. This pattern is most often seen during the second stage of labor. The presence of a saltatory pattern, especially when paired with decelerations, should warn the physician to look for and try to correct possible causes of acute hypoxia and to be alert for signs that the hypoxia is progressing to acidosis. Although it is a nonreassuring pattern, the saltatory pattern is usually not an indication for immediate delivery. Option C: Auscultation of the fetal heart rate (FHR) is performed by external or internal means. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the FHR during a uterine contraction and for 30 seconds thereafter to identify fetal response. The transducer uses Doppler ultrasound to detect fetal heart motion and is connected to an FHR monitor. The monitor calculates and records the FHR on a continuous strip of paper. Option D: Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm and is considered a nonreassuring pattern. Tachycardia is considered mild when the heart rate is 160 to 180 bpm and severe when greater than 180 bpm. Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia or congenital anomalies rather than hypoxia alone.

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After the attachment of the monitor, the initial nursing assessment is which of the following? A. Identifying the types of accelerations B. Assessing the baseline fetal heart rate C. Determining the frequency of the contractions D. Determining the intensity of the contractions

Assessing the baseline fetal heart rate Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority. Option A: The FHR recordings may be interpreted as reassuring, nonreassuring or ominous, according to the pattern of the tracing. Reassuring patterns correlate well with a good fetal outcome, while nonreassuring patterns do not. Evaluation of fetal well-being using fetal scalp stimulation, pH measurement, or both, is recommended for use in patients with nonreassuring patterns. Option C: Frequency is based on the time between the start of one contraction and the start of the next contraction. Time the frequency of contractions by noting the time when one contraction starts and the time when the next contraction starts. Option D: The intensity of the contractions can be estimated by touching the uterus. The relaxed or mildly contracted uterus usually feels about as firm as a cheek, a moderately contracted uterus feels as firm as the end of the nose, and a strongly contracted uterus is as firm as the forehead.

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured

Auscultating the fetal heart. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required. During labor, cardiotocographic monitoring is often employed to monitor uterine contractions and fetal heart rate over time. Clinicians monitor fetal heart tracings to evaluate for any signs of fetal distress that would warrant intervention as well as the adequacy or inadequacy of contractions. Option B: When women first present to the labor and delivery unit, vital signs, including temperature, heart rate, oxygen saturation, respiratory rate, and blood pressure, should be obtained and reviewed for any abnormalities. The patient should be placed on continuous cardiotocographic monitoring to ensure fetal wellbeing. The patient's prenatal record, including obstetric history, surgical history, medical history, laboratory, and imaging data, should undergo review. Finally, a history of present illness, review of systems, and physical exam, including a sterile speculum exam, will need to take place. Option C: Labor is a natural process, but it can suffer interruption by complicating factors, which at times necessitate clinical intervention. The management of low-risk labor is a delicate balance between allowing the natural process to proceed while limiting any potential complications. Option D: Cervical exams are usually performed every 2 to 3 hours unless concerns arise and warrant more frequent exams. Frequent cervical exams are associated with a higher risk of infection, especially if a rupture of membranes has occurred. Women should be allowed to ambulate freely and change positions if desired.

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin

Below the umbilicus on the right side Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presentation), the back would be below the umbilicus and on the right side. Option A: The baby's heartbeat is loudest in its upper chest or upper back, depending on which way the baby is facing. Option B: If you hear the heartbeat loudest above the mother's umbilicus, the baby may be in the breech position Option D: If you hear the heartbeat loudest below the mother's umbilicus, the baby is probably head down.

When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. Stop the oxytocin infusion B. Change the client's position C. Prepare for immediate delivery D. Take the client's blood pressure

Change the client's position. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord. Variable decelerations can be seen resulting from the fetal movement if the fetus is premature. In the term fetus, variable decelerations result from vagus nerve-mediated parasympathetic effects on the heart. There are several theories regarding the pathway that leads to this vagal stimulation. Option A: If a patient is having uterine tachysystole, reducing the number of contractions by decreasing oxytocin or administration of a beta-agonist may be appropriate. Option C: Ultimately, if the fetal heart tracing is persistently abnormal, facilitating delivery is indicated. In the term, laboring patient, an operative vaginal delivery may be considered. If the patient is remote from delivery, it may indicate the need for cesarean delivery. In a patient with preterm prelabor rupture of membranes, induction or augmentation of labor may be the next step if the fetus is in the vertex presentation. Alternatively, cesarean delivery may be indicated if the fetus is in the breech presentation. Option D: Fetal heart rate tracings reflect the response of the fetal central nervous system to intrauterine hypoxia. Variable decelerations are under vagal mediation through baroreceptors or chemoreceptors. Possibly, direct cord compression leads to fetal hypertension, which in turn leads to baroreceptor response and subsequent vagal-mediated heart rate decrease. Alternatively, hypoxemia resulting from decreased uteroplacental perfusion triggers chemoreceptors, which in turn lead to a cascade of physiologic responses that ultimately result in vagal-mediated heart rate decrease.

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A. The umbilical cord shortens in length and changes in color B. A soft and boggy uterus C. Maternal complaints of severe uterine cramping D. Changes in the shape of the uterus

Changes in the shape of the uterus Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vaginal), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. Option A: The most reliable sign is the lengthening of the umbilical cord as the placenta separates and is pushed into the lower uterine segment by progressive uterine retraction. Placing a clamp on the cord near the perineum makes it easier to appreciate this lengthening. Never place traction on the cord without countertraction on the uterus above the symphysis; otherwise, one may mistake cord lengthening due to impending prolapse or inversion for that of uncomplicated placental separation. Option B: The uterus takes on a more globular shape and becomes firmer. This occurs as the placenta descends into the lower segment and the body of the uterus continues to retract. This change may be clinically difficult to appreciate. Option C: Following the delivery of the fetus, uterine contractions continue and the placenta is sheared from the underlying endometrium. This separation primarily occurs by a reduction in the surface area of the placental site as the uterus shrinks.

The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: A. Clear and dark amber in color B. Milky, greenish yellow, containing shreds of mucus C. Clear, almost colorless, and containing little white specks D. Cloudy, greenish-yellow, and containing little white specks

Clear, almost colorless, and containing little white specks. By 36 weeks gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present. Amniotic fluid is usually clear to pale yellow in color. It should be odorless, or slightly sweet in odor—although some say it has a bleach-like smell. Option A: Dark fluid can also be seen with an intrauterine fetal demise (IUFD) when the fetus has died during pregnancy. Option B: In full-term or near-term pregnancies, green or brown fluid may indicate the baby has had a bowel movement (meconium), which contributes to the color change. This can be an indication of a baby in distress or simply that the pregnancy has extended enough for the baby to pass that first stool in utero. Option D: The amniotic fluid may also be blood-tinged, especially during labor, if the cervix has started dilating, or if there are placental problems.

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client's bedside

Continuous electronic fetal monitoring Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin. Continuous electronic fetal monitoring should be performed for a minimum of 20 minutes before starting oxytocin and should be continued until the baby is delivered. Option A: Complete bed rest is not a necessity before initiating Pitocin infusion. Pitocin is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable for reasons of fetal or maternal concern, in order to achieve vaginal delivery. Option C: It is unnecessary to administer IV antibiotics before Pitocin infusion. Immediately administer broad-spectrum antibiotics only to patients with severe postabortion infection. Option D: A code cart may be placed beside the client but in case of overdose, contact the Poison Control Center.

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: A. Complete bed rest for the remainder of the pregnancy. B. Delivery of the fetus. C. Strict monitoring of intake and output. D. The need for weekly monitoring of coagulation studies until the time of delivery.

Delivery of the fetus. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy. Option A: Placental abruption occurs when there is a compromise of the vascular structures supporting the placenta. In other words, the vascular networks connecting the uterine lining and the maternal side of the placenta are torn away. These vascular structures deliver oxygen and nutrients to the fetus. Disruption of the vascular network may occur when the vascular structures are compromised because of hypertension or substance use or by conditions that cause stretching the uterus. The uterus is a muscle and is elastic whereas the placenta is less elastic than the uterus. Option C: Evaluation of vital signs to detect tachycardia or hypotension, which may be indicators of a concealed hemorrhage are taken. Blood specimens such as a complete blood count (CBC), fibrinogen, clotting profile, and type and RH may be collected. These laboratory values will not aid in the diagnosis of placental abruption but will provide baseline data against which to evaluate the patient's condition over time. Option D: Women classified with a class 1 or mild placental abruption and no signs of maternal or fetal distress and a pregnancy less than 37 weeks gestation may be managed conservatively. These patients are usually admitted to the obstetrical unit for close monitoring of maternal and fetus status. Intravenous access and blood work for type and crossmatch is part of the plan of care. The maternal-fetal dyad will continue to be monitored until there is a change in condition or until fetal maturity is reached.

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being. B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse-midwife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing.

Document the findings and tell the mother that the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve. Option B: Inform the mother that they are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation. The presence of accelerations is considered a reassuring sign of fetal well-being. Option C: Accelerations are the basis for the nonstress test (NST). The presence of at least two accelerations, each lasting for 15 or more seconds above baseline and peaking at 15 or more bpm, in a 20-minute period is considered a reactive NST. Option D: The FHR is controlled by the autonomic nervous system. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. Progressive vagal dominance occurs as the fetus approaches term and, after birth, results in a gradual decrease in the baseline FHR. Stimulation of the peripheral nerves of the fetus by its own activity (such as movement) or by uterine contractions causes acceleration of the FHR.

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: A. Exhaustion B. Valsalva's maneuver C. Involuntary grunting D. Fear of losing control

Fear of losing control Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor. In women who have delivered vaginally previously, whose bodies have acclimated to delivering a fetus, the second stage may only require a brief trial, whereas a longer duration may be required for a nulliparous female. Option A: Labour as a life event is characterized by tremendous physiological and psychological changes that require major behavioral adjustments in a short period of time. Option B: Exercise involving the Valsalva maneuver (holding one's breath during exertion) because it can cause increased intra-abdominal pressure. Option C: Labour presents a physical and psychological challenge for women. The latter stages of pregnancy can be a difficult time emotionally. Fear and apprehension are experienced alongside excitement. There are emotions both positive and negative that will affect the woman's birth experience.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A. Disseminated intravascular coagulation B. Chronic hypertension C. Infection D. Hemorrhage

Hemorrhage Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. Vaginal bleeding secondary to placenta previa can lead to postpartum hemorrhage requiring a blood transfusion, hysterectomy, maternal intensive care admission, septicemia, and maternal death. Option A: Out of 4,334 obstetrical admissions, DIC was diagnosed in 40 (0.92%) patients. Risk factors noted were eclampsia 28 (70%), abruptio placentae 7 (17.5%), septicaemia 3 (7.5%), pancytopenia 1 (2.5%), and 1 (2.5%) patient had DIC secondary to hemorrhagic shock due to placenta previa. Option B: Women with chronic hypertension had a relative risk of 1.2 (95% confidence interval 0.4 to 3.7) for placenta previa compared with normotensive women. However, the risk of pregnancy-induced hypertension was reduced by half among those with placenta previa (relative risk 0.5, 95% confidence interval 0.3 to 0.7). Option C: Patients with placenta previa presenting with vaginal bleeding have intra-amniotic infection in 5.7% of the cases, and IAI in 17.9%. IAI in patients with placenta previa and vaginal bleeding is a risk factor for preterm delivery within 48 h.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A. Less pressure on her cervix. B. Increased efficiency of contractions. C. Decreased number of contractions. D. The need for increased maternal blood pressure monitoring.

Increased efficiency of contractions Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Option A: Amniotomy is usually performed for the purpose of inducing or expediting labor or in anticipation of the placement of internal monitors (uterine pressure catheters or fetal scalp electrodes). It is typically done at the bedside in the labor and delivery suite. Option C: It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix. Option D: The nurse has a very important rule in the assessment and continuous monitoring of pregnant women in labor. The nurse should be very vigilant and report any untoward change in the hemodynamic status of the pregnant woman to the clinician at all times.

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A. A form of biofeedback to enhance bearing down efforts during delivery. B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus. C. The application of pressure to the sacrum to relieve a backache. D. Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest.

Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before a transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus. Option A: Women using biofeedback during childbirth reported significantly lower pain: from admission to labor and delivery, at delivery, and 24-hr postpartum. Also, women in the biofeedback group labored an average of 2 hr less and used 30% fewer medications. The results of a study suggest that EMG biofeedback may be effective in reducing levels of acute pain experienced by childbearing women. Option C: Low back pain in pregnancy is generally ascribed to the many changes in load and body mechanics that occur during the carrying of a child. It is normal to gain between 20 and 40 pounds during pregnancy. This clearly shifts the body's center of gravity anteriorly and increases the moment arm of forces applied to the lumbar spine. Option D: The primary hormones involved include estrogen, progesterone, and oxytocin. Oxytocin is one of the most widely studied hormones involved in uterine contractions. It decreases Ca2+ efflux, by inhibiting the Ca2+/ATPase of the myometrial cell membrane which pumps calcium from the inside to the extracellular space, and increases Ca2+ influx, as well as causes the release of Ca2+ from the SR via IICR.

A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? A. Keeping the significant other informed of the progress of the labor. B. Providing comfort measures. C. Monitoring fetal heart rate. D. Changing the client's position frequently.

Monitoring fetal heart rate. The priority is to monitor the fetal heart rate. The continuous monitoring of the external fetal heart rate provides insight into fetal well-being. The assessment of the fetal heart rate could be performed utilizing external or internal fetal heart rate monitoring. An alternative is fetal heart rate auscultation every 15 minutes in the first stage of labor and after each contraction during the second stage of labor. In the interpretation of the fetal heart rate strip millimeters considered are baseline viability, basal heart rate, cardiac accelerations or decelerations, endocrine activity. Strip abnormalities are characterized based on consideration of the above parameters. Option A: At admission to labor and delivery, prenatal records and obstetric history should be reviewed because these optimally inform the provider to the best intrapartum obstetric care. This care includes the determination of the static gestational age. Option B: Most labor and delivery units will have an established protocol for administration of oxytocin that entails the administration of the proper medication and dosage, as well as criteria for an incremental increase as clinically warranted. The protocols also include monitoring maternal and fetal vital signs, as well as the atria, for discontinuation of the medication in the event of concern for tachycardia systole all fetal well-being. Option D: The uterine activity is assessed by external tocometry and targeted at 3 to 5 contractions in the 10-minute window. The contractions should last 30 to 40 seconds to be effective. Internal intrauterine pressure assessment using a catheter could be utilized, in which case marked medial units are used and targeted at more than 200 Montevideo units in a 10-minute window. The monitoring of uterine contractions should be continuous during labor.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client's coach to continue to encourage breathing exercises. B. Encourage the client to continue pushing with each contraction. C. Continue monitoring the fetal heart rate. D. Notify the physician or nurse-midwife.

Notify the physician or nurse-midwife. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse-midwife needs to be notified. Option A: Steps can be taken to help the fetus get more oxygen, such as having the mother change position. If these procedures do not work, or if further test results suggest the fetus has a problem, the ob-gyn or other health care professional may decide to deliver right away. Option B: Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagina into the uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured. Option C: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A. Prepare the client for an ultrasound. B. Obtain equipment for external electronic fetal heart monitoring. C. Obtain equipment for a manual pelvic examination. D. Prepare to draw a Hgb and Hct blood sample.

Obtain equipment for a manual pelvic examination. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. Option A: A diagnosis of placenta previa is made by ultrasound. A patient presenting with vaginal bleeding in the second or third trimester should receive a transabdominal sonogram before a digital examination. If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. Transvaginal sonogram has been shown to be superior to a transabdominal sonogram and is safe. Option B: External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia. Placental abruption presents with severe abdominal pain, vaginal bleeding, and electronic fetal monitoring may show tachysystole and a nonreassuring fetal heart tracing; this too can lead to high morbidity in mortality to the fetus and mother secondary to hemorrhage. Option D: The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. A leading cause of third-trimester hemorrhage, placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor; this leads to bleeding at the implantation site, because the uterus is unable to contract adequately and stop the flow of blood from the open vessels.

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: A. Breech B. Transverse C. Occiput anterior D. Occiput posterior

Occiput posterior A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain. Option A: Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term. Option B: The transverse lie position is where the baby's head is on one side of the mother's body and the feet on the other, rather than having the head close to the cervix or close to the heart. The baby can also be slightly at an angle, but still more sideways, than up or down. Option C: The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off-center in the pelvis with the back of the head toward the mother's left thigh.

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? A. Medication that will provide sedation B. Increased hydration C. Oxytocin (Pitocin) infusion D. Administration of a tocolytic medication

Oxytocin (Pitocin) infusion. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor that slows. Hypotonic labor is an abnormal labor pattern, notable especially during the active phase of labor, characterized by poor and inadequate uterine contractions that are ineffective to cause cervical dilation, effacement, and fetal descent, leading to a prolonged or protracted delivery. Option A: Provided there are no contraindications. Oxytocin is the medication of choice for augmenting contractions. The dosage regimen should be titrated to effect for achieving adequate uterine contractions. However, dosing generally does not exceed 30milliunit/ minute. The usual protocol is 5 units of oxytocin in 500mls of 5% Dextrose intravenous infusion, starting with 10 drops/min and gradually titrating the rate to achieve a contraction rate of at least 3 per minute. Option B: Maintain adequate hydration. Encourage ambulation and avoid supine position. Although these are not proven to improve contractions or prolonged labor due to hypocontractility, they may improve the comfort of the patient. Option D: A combination of amniotomy and oxytocin augmentation is more effective in the management of hypocontractile labor than amniotomy alone when instituted early in the active phase.

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position. B. Call the delivery room to notify the staff that the client will be transported immediately. C. Gently push the cord into the vagina. D. Find the closest telephone and stat page the physician.

Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation. Option B: The definitive management of umbilical cord prolapse is expedient delivery; this is usually by cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and, thus, preferable, but this should only occur under the presence and guidance of an experienced obstetrician. Option C: No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Decompression should be done manually by the medical provider through the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting part off the umbilical cord. The provider should be conscientious not to place any additional pressure on the cord, as this can cause vasospasm and worsen outcomes. Option D: The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is visibly protruding from the introitus, it should remain warm and moist because the ambient temperature is significantly colder than the temperature in the uterus and can result in vasospasm of the umbilical arteries, contributing to fetal hypoxia. One method described preventing this is the replacement of the cord into the vaginal vault followed by insertion of a moist tampon to keep it in place.

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: A. Hematoma B. Placenta previa C. Uterine atony D. Placental separation

Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Option A: A hematoma is a bad bruise. It happens when an injury causes blood to collect and pool under the skin. The pooling blood gives the skin a spongy, rubbery, lumpy feel. A hematoma usually is not a cause for concern. It is not the same thing as a blood clot in a vein, and it does not cause blood clots. Option B: Placenta previa occurs when a baby's placenta partially or totally covers the mother's cervix — the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery. If the woman has placenta previa, she might bleed throughout her pregnancy and during her delivery. Option C: Atony of the uterus, also called uterine atony, is a serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage.

A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A. A loud mouth B. Low self-esteem C. Hemorrhage D. Postpartum infections

Postpartum infections Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Good nutrition is the best way to prevent anemia if the woman is pregnant or trying to become pregnant. Eating foods high in iron content (such as dark green leafy vegetables, red meat, fortified cereals, eggs, and peanuts) can help ensure that she maintains the supply of iron her body needs to function properly. The obstetrician will also prescribe vitamins to ensure that the woman has enough iron and folic acid. Make sure to get at least 27 mg of iron each day. If the woman does become anemic during pregnancy, it can usually be treated by taking iron supplements. Option A: The amount of blood in the body increases by about 20-30 percent, which increases the supply of iron and vitamins that the body needs to make hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen to other cells in the body. Option B: Mild anemia is normal during pregnancy due to an increase in blood volume. More severe anemia, however, can put the baby at higher risk for anemia later in infancy. In addition, if the mother is significantly anemic during the first two trimesters, she is at greater risk for having a preterm delivery or low-birth-weight baby. Being anemic also burdens the mother by increasing the risk of blood loss during labor and making it more difficult to fight infections. Option C: Anemia does not specifically present a risk for hemorrhage. Severe anemia may weaken uterine muscular strength or lower resistance to infectious diseases, contributing to postpartum hemorrhage and subsequent maternal mortality. However, the severity of anemia that places a woman at a greater risk of experiencing postpartum hemorrhage or a debilitating and clinically relevant blood loss has not been investigated. Indeed, the impact of anemia on the extent of blood loss at childbirth and postpartum is not well-understood.

A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: A. Monitor the Pitocin infusion closely B. Provide pain relief measures C. Prepare the client for an amniotomy D. Promote ambulation every 30 minutes

Provide pain relief measures Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. The psychological preparation of patients before labor appears to improve pain tolerance during labor. This should begin during routine antenatal visits and the counseling for labor analgesia. This preparation may serve to reduce the need for neuraxial analgesia in labor, which is a probable predisposing factor for hypocontractile labor. Option A: Provided there are no contraindications, oxytocin is the medication of choice for augmenting contractions. The dosage regimen should be titrated to effect for achieving adequate uterine contractions. However, dosing generally does not exceed 30milliunit/ minute. Option C: Membrane rupture (amniotomy) stimulates contractions by the release of prostaglandins and reflex stimulation of the uterus when the presenting part becomes closely applied to the lower uterine segment. Amniotomy should be attempted when vaginal delivery is probable; where cervical dilatation > 4 cm, there is adequate fetal descent (station -2 or lower), and the presenting part is well-applied to the lower uterine segment. Option D: Encourage ambulation and avoid supine position. Although these are not proven to improve contractions or prolonged labor due to hypocontractility, they may improve the comfort of the patient.

At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: A. Discontinue the catheter if the reading is not above 80%. B. Discontinue the catheter if the reading does not go below 30%. C. Advance the catheter until the reading is above 90% and continue monitoring. D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring.

Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings. Fetal pulse oximetry measures how much oxygen the baby's blood is carrying. It uses a probe that sits on the baby's head whilst in the uterus and vagina during labor. The probe is said not to interfere with the woman's mobility during labor. Option A: This method has two potential advantages over conventional fetal heart rate monitoring: (i) it directly measures the proportion of hemoglobin that is carrying oxygen: thus, oxygenation, the primary variable underlying the tissue-damaging effects of hypoxia/ischemia is being monitored; and (ii) it relies on an established, safe, noninvasive, widely?used technology found in every modern intensive care unit and operating theatre. Option B: A variety of fetal pulse oximetry sensors has been studied. These are placed during a vaginal examination to attach to the top of the fetal head by suction (Arikan 2000) or clip (Knitza 2004), lie against the fetal temple or cheek (Mallinckrodt 2000; Nellcor 2004), or to lie along the fetal back (Prothia 2014). The sensor remains in situ and fetal pulse oximetry values are recorded for approximately 81% of the monitoring time (East 1997). Option C: A prospective observational study found a low pulse oximetry oxygen saturation < 30% for at least 10 minutes correlates highly with fetal acidosis in cases of nonreassuring fetal heart rate (Nonnenmacher 2010). A novel fetal phantom based on actual fetal parameters showed that the wireless oximeter was capable of identifying 4% and 2% changes in diameter between the diastolic and systolic point in arteries of over 0.2 and 0.4 mm inner diameter, respectively (Stubán 2009).

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A. Over the fetus that is most anterior to the mother's abdomen. B. Over the fetus that is most posterior to the mother's abdomen. C. So that each fetal heart rate is monitored separately. D. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

So that each fetal heart rate is monitored separately. In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Simultaneous monitoring of twins is preferable to non simultaneous monitoring to discriminate between their separate FHRs (ACOG, 1989). Synchronizing the internal clocks of both monitors will help produce accurate documentation. Otherwise, time increments should be documented on both monitor tracings for later comparison, to ensure that each twin has been monitored. If the monitor strips are synchronous, portable real-time ultrasound can be used to verify that both twins are being monitored independently Option A: Among the advantages of simultaneous twin monitoring is the increased likelihood that both twins are being monitored with potentially less nursing time. Option B: The nonstress test (NST) is the most widely used method of evaluating twins for any of the aforementioned risk factors. Normative data for simultaneous twin NSTs show synchrony or similarity in the tracings with incidences of 57.14% and 58% in twins monitored from 27?weeks until term. Option D: Synchrony is thought by some to occur because the first twin's movement produces a vibration and stimulates movement and FHR accelerations in the second twin. Recently, this idea was supported in a limited investigation of twins in which vibratory acoustic stimulation evoked an immediate transition from asynchronous to synchronous FHR tracings in all 16 tests carried out in the study (Sherer, Abramowicz, D'Amico, Caverly, & Woods, 1991).

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. Perform a vaginal examination Reposition the client. Administer oxygen by face mask at 8 to 10 L/min Check the client's blood pressure and heart rate Stop Pitocin infusion.

Stop Pitocin infusion. Check the client's blood pressure and heart rate Reposition the client. Administer oxygen by face mask at 8 to 10 L/min Perform a vaginal examination If uterine hypertonicity occurs, the nurse immediately will intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the non-additive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for a prolapsed cord. Oxytocin is a natural hormone, which causes the uterus (womb) to have regular, painful contractions and labor to start. It is available as an intravenous (into a vein (IV)) drug and infused slowly to artificially stimulate labor if doctors or midwives feel that it is necessary to accelerate the birth of the baby, or if the mother requests it. Risks associated with using IV oxytocin to stimulate uterine contractions include the woman having contractions that are too long or too frequent (uterine hyperstimulation), which can lead to changes in the baby's heart rate and the need for an emergency cesarean. Stopping oxytocin infusion once active labor has started could result in more natural childbirth, particularly if the risk of uterine overstimulation and the need for immediate cesarean section is reduced. Also, the overall total dose of oxytocin the mother received would be reduced, which could lead to fewer adverse effects (e.g. maternal nausea, vomiting, and headache, or changes to the baby's heart rate). Discontinuing IV oxytocin probably reduces the risk of women having contractions that become too long or too strong resulting in changes to the baby's heart rate (three trials, 486 women).

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria

Swelling of the calf in one leg DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis. Option B: Fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Derangement of the fibrinolytic system further contributes to intravascular clot formation, but in some cases, accelerated fibrinolysis may cause severe bleeding. Hence, a patient with DIC can present with a simultaneously occurring thrombotic and bleeding problem, which obviously complicates the proper treatment. Option C: Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolong). Exposure to tissue factor (TF) in the circulation occurs via endothelial disruption, tissue damage, or inflammatory or tumor cell expression of procoagulant molecules (including TF). TF activates coagulation via the extrinsic pathway involving factor VIIa. The TF-VIIa complex activates thrombin, which cleaves fibrinogen to fibrin while simultaneously causing platelet aggregation.. Option D: The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. With acute DIC, the physical findings are usually those of the underlying or inciting condition; however, patients with the acute disease (ie, the hemorrhagic variety associated with excess plasmin formation) have petechiae on the soft palate, trunk, and extremities from thrombocytopenia and ecchymosis at venipuncture sites. These patients also manifest ecchymosis in traumatized areas.

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: A. Until the time it is completely over B. To the end of a second contraction C. To the beginning of the next contraction D. Until the time that the uterus becomes very firm

To the beginning of the next contraction This is the way to determine the frequency of the contractions. When timing contractions, start counting from the beginning of one contraction to the beginning of the next. The easiest way to time contractions is to write down on paper the time each contraction starts and its duration, or count the seconds the actual contraction lasts. Option A: Contractions are intermittent, with a valuable rest period for the mother, the baby, and her uterus following each one. When timing contractions, start counting from the beginning of one contraction to the beginning of the next. Option B: As the strength of each contraction increases, the peaks will come sooner and last longer. There should be some regularity or pattern when timed. Persistent contractions that have no rhythm but are five-to-seven minutes apart or less should be reported to the physician or midwife. Option D: Contractions are often described as a cramping or tightening sensation that starts in the back and moves around to the front in a wave-like manner. Others say the contraction feels like pressure in the back. During a contraction, the abdomen becomes hard to the touch.

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding

Uterine tenderness/pain In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Option A: Placental abruption occurs when there is a compromise of the vascular structures supporting the placenta. In other words, the vascular networks connecting the uterine lining and the maternal side of the placenta are torn away. These vascular structures deliver oxygen and nutrients to the fetus. Option B: The abdomen will feel hard and board like on palpation as the blood penetrates the myometrium and causes uterine irritability. Disruption of the vascular network may occur when the vascular structures are compromised because of hypertension or substance use or by conditions that cause stretching the uterus. The uterus is a muscle and is elastic whereas the placenta is less elastic than the uterus. Therefore, when the uterine tissue stretches suddenly, the placenta remains stable and the vascular structure connecting the uterine wall to the placenta tears away. Option D: If bleeding is present, the quantity and characteristic of the blood, as well as the presence of clots, is evaluated. Remember, the absence of vaginal bleeding does not eliminate the diagnosis of placental abruption.

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. Early decelerations B. Variable decelerations C. Late decelerations D. Short-term variability

Variable decelerations Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. This is followed by occlusion of the umbilical artery, which results in a sharp downslope. Finally, the recovery phase is due to the relief of the compression and the sharp return to the baseline, which may be followed by another healthy brief acceleration or shoulder Option A: Early decelerations result from pressure on the fetal head during a contraction. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction Option C: Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. The descent and return are gradual and smooth. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. Option D: Short-term variability refers to the beat-to-beat range in the fetal heart rate. The FHR is under constant variation from the baseline. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors, and cardiac responsiveness. Prematurity decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks.