Lippincott L&D at Risk

A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response?

"Babies need comforting and cuddling; meeting these needs will not spoil him." Rationale: It is a common misconception that picking up an infant whenever he or she cries will spoil the child. Infants need to be cuddled and comforted when they are upset. Comforting may be as simple as feeding or changing a wet diaper.An infant typically cries because of a need, for example, being hungry, needing to be burped, or having a wet diaper. Responding to the infant's needs in a timely fashion by picking the infant up helps to develop trust. Allowing the infant to cry for 45 minutes would be inappropriate and too long to wait.Assuming that the infant is hungry each time he cries could lead to overfeeding.

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching?

"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher." Rationale: Because of the client's increased risk for infection, successful teaching is indicated when the client states that she will contact the primary care provider if her temperature is 100.4° F (38° C) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted because water in the shower does not enter the vagina and increase the risk of infection. A fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.

A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the teaching when the client makes which statement?

"If left untreated, my baby might be born with an infection." Rationale: Chorioamnionitis is a serious intrapartum infection that may result in fetal tachycardia and a hypotonic labor pattern. If left untreated, infected amniotic fluid in the fetal lungs may result in an infection, such as pneumonia, during the neonatal period. Typically chorioamnionitis results in fetal tachycardia, not bradycardia. Chorioamnionitis usually results in a maternal fever and tachycardia. It is not associated with either hypotonic or hypertonic labor patterns. No relationship is known between being overweight and development of chorioamnionitis.

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood?

"The anesthetic may cause a severe headache, which is treatable." Rationale: Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, or using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.

Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider?

A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Rationale: When used properly, a vacuum extractor-assisted birth causes fewer complications for the mother and the baby than a forceps-assisted birth. A cephalhematoma may occur with the use of forceps or vacuum extractors. Instruments are used during birth when individually necessary. Assisted deliveries may increase the risk for postpartum hemorrhage.

The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next?

Administer oxygen at 8 to 10 L by mask. Rationale: Late decelerations signal poor placental perfusion. Therefore, oxygen should be administered at 8 to 10 L by mask to improve fetal hypoxia. The nurse should also stop the oxytocin infusion, turn the client onto her side, and report the pattern to the health care provider.Informing the client about fetal well-being occurs throughout the labor process, not just if problems arise.If the late deceleration pattern persists or if decreased variability occurs, then cesarean birth may be indicated.Although the contraction pattern should be monitored throughout the induction of labor, the priority here is to provide oxygen to the compromised fetus.

A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, which actionshould the nurse take next?

Administer oxygen by face mask. Rationale: The client's symptoms are indicative of amniotic fluid embolism, which is a medical emergency. After calling for assistance, the first action should be to administer oxygen by face mask or cannula to ensure adequate oxygenation of mother and fetus. If the client needs cardiopulmonary resuscitation, this can be started once oxygen has been administered. If the client survives, disseminated intravascular coagulation will probably develop, and the client will need intravenous fibrinogen and heparin. Oxytocin, a vasoconstrictor, is not warranted for amniotic fluid embolism.

A client with active genital herpes is admitted to the labor and birth unit. During the first stage of labor. Which type of birth should the nurse anticipate for this client?

Cesarean Rationale: For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.

A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What should the nurse do next?

Continue monitoring the client and fetus. Rationale: Fetal heart rate is normally between 110 and 160 bpm. The finding of a fetal heart rate at 140 bpm is within this normal range. Therefore, the nurse should continue to monitor the client and fetus.A fetal heart rate of 140 bpm is within the normal range of 110 to 160 bpm. Neither the fetus nor the mother is in any distress. Therefore, oxygen is not necessary.Because the fetal heart rate is not an abnormal reading, there is no need to notify the primary care provider, and the fetal heart rate does not need to be checked again in 5 minutes. However, continued monitoring based on agency policy is warranted.

A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?

Continuous fetal heart rate monitoring will be implemented. Rationale: Uteroplacental insufficiency is associated with a postterm fetus; therefore, it is recommended that the fetal heart rate and contraction pattern be monitored throughout the labor and birth process. In addition, intravenous oxytocin, which is frequently used for induction of labor, may result in hyperstimulation of the uterus. Therefore, monitoring the client is critical.One ultrasound may be performed to assess position and confirm gestational age.A scalp pH may be performed if there is evidence of fetal bradycardia, late decelerations, and a possibility of fetal hypoxia. Even so, 5 to 10 scalp pH measurements would be highly unusual.Postterm clients generally do not have a decreased amount of amniotic fluid (oligohydramnios).

The primary care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?

Contractions cease. Rationale: Tocolytics are used to stop uterine contractions. Sedation is not its purpose of a tocolytics.Tocolyitics have no effect on placental perfusion or the fetal pulmonary system or lung function.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

Contractions will be stronger and more uncomfortable and will peak more abruptly. Rationale: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug?

Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. Rationale: The goal of oxytocin administration in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h is too rapid for the induction/augmentation process.

A 30-year-old G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. What should the nurse do first?

Discontinue the oxytocin infusion. Rationale: The fetal monitor strip shows late decelerations. The first intervention would be to turn off the oxytocin because the medication is causing the contractions. The stress caused by the contractions demonstrates that the fetus is not being perfused during the entire contraction (as shown by the late decelerations). There is no time to continue to observe in this situation; intervention is a priority. The client is attached to an internal fetal monitor, which would be possible only if her membranes had already ruptured. If the fetus continues to experience stress, fetal oximetry may be initiated.

A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?

Document fetal well-being. Rationale: Accelerations that are episodic and occur during fetal movement demonstrate fetal well-being. Turning the client to the left side, applying oxygen by face mask and notifying the HCP are interventions used for late and variable decelerations indicating the fetus is not tolerating the induction process well.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?

Maintain a patent airway. Rationale: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure.Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure.Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first?

Place gentle pressure upward on the fetal head. Rationale: The nurse should place a hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother, but until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?

Place the client in a Trendelenburg position. Rationale: The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client's head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean birth is usually performed. Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus. Pushing results in further cord compression and decreased fetal heart rate.With cord prolapse, an immediate cesarean birth is indicated. There is no need to cover the cord to avoid damage or tearing

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention?

Prepare for an emergency cesarean birth. Rationale: Because the abnormal FHR and amniotic fluid color suggest fetal distress, the nurse should prepare for an energency cesarean birth. Giving oxytocin may inrease fetal distress. Applying a fetal scalp electrode and having the client push are inappropriate actions that wouldn't address this emergency situation.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?

Remain in a side-lying position with the head elevated. Rationale: The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.

A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Report a heart rate greater than 120 beats/minute to the health care provider. Rationale: Because terbutaline can cause tachycardia, the client should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client does not need to contact the health care provider if such movement occurs. The client experiencing premature labor must maintain bed rest at home.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion. Rationale: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.

Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is >20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first?

Turn off the oxytocin infusion. Rationale: The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise?

allowing the client to ambulate as tolerated Rationale: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?

client at 38 weeks' gestation with active herpes lesions Rationale: Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given a trial of labor before a cesarean. The client with a fetus in the ROP position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months' gestation, the breech position is not a concern.

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?

complete uterine rupture Rationale: In complete uterine rupture, the client feels a sharp pain in the lower abdomen and contractions stop. Fetal heart rate also stops within a few minutes. In abruptio placentae, uterine instability would continue to be indicated by the fetal heart monitor tracing. With cord prolapse, contractions would continue and the client wouldn't experience pain from the prolapse itself. Although vaginal bleeding occurs with partial placenta previa, the client has no pain outside of the expected pain of contractions.

A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25% but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?

dinoprostone Rationale: Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in early labor and has no influence on the cervix. Betamethasone is a corticosteroid given to mature fetal lungs.

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?

encouraging them to ask questions Rationale: By encouraging parents to ask questions during information-sharing sessions, the nurse can clarify misconceptions and determine the parents' understanding of information. A better understanding of what is happening allows the parents to feel some control over the situation. Assessing the adequacy of the parents' coping skills is important but secondary to encouraging them to express their concerns. The questions they ask and their interactions with the nurse may provide clues to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At this point, there is no way for the nurse to know whether the child will be fine. Written materials are appropriate for augmenting the nurse's verbal communication. However, these are secondary to encouraging questions.

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important?

fetal heart rate Rationale: The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. While measuring maternal pulse is important, this vital sign does not tell the nurse as much about fetal perfusion as the fetal heart rate or maternal blood pressure. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy.The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia.Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, although important for any client, is not the priority following epidural anesthesia.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to:

prevent seizures. Rationale: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:

promote fetal lung maturity. Rationale: Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. The drug has no effect on contractions, fetal growth, or infection.

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

promoting adequate hydration Rationale: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?

temperature Rationale: Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.

A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to order:

terbutaline Rationale: Terbutaline, a beta-receptor agonist, is approved by the Food and Drug Administration (Canada's Food and Drug Act and Regulation) for inhibiting preterm uterine contractions. Betamethasone accelerates surfactant production in preterm labor. Dinoprostone induces fetal expulsion and promotes cervical dilation and softening. Ergonovine is used to impede uterine blood flow — for example, in hemorrhage.

A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug?

to accelerate fetal lung maturity Rationale: Corticosteroids, such as betamethasone, are prescribed for clients who are preterm to accelerate fetal lung maturity and reduce the incidence and severity of respiratory distress syndrome.Infection would be treated with antibiotics. Tocolytic therapy is used to reduce contractions.The nurse should monitor the fetal heart rate pattern, but betamethasone will not improve the fetal heart rate.