Maternity- Labor and Delivery and Associated Complications

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1. a change in the uterine contour 2. sudden and sharp abdominal pain 3. a shortening of the umbilical cord 4. a decrease in blood loss from the introitus

1 Rationale: signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. the client may experience vaginal fullness but not sudden and sharp abdominal pain

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1. baseline fetal heart rate 2. intensity of contractions 3. maternal blood pressure 4. frequency of contractions

1 Rationale: the nurse should first determine the baseline fetal heart rate. although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1. determine the fetal heart rate 2. prepare for delivery immediately 3. monitor the contraction pattern 4. note the amount, color, and odor of the amniotic fluid

1 Rationale: when the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional findings? 1. soft abdomen on palpation 2. uterine tenderness on palpation 3. no complaints of abdominal pain 4. lack of uterine irritability or tetanic contractions

2 Rationale: vaginal bleeding in a pregnant client is most often caused by placenta previa or placental abruption. uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. a sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax

A woman in active labor has contractions every 2 to 3 mins that last for 45 seconds. The fetal heart rate between contractions is 100 bpm. On the basis of these findings which is the priority nursing action? 1. monitor the maternal vital signs 2. notify the RN immediately 3. continue monitoring labor and fetal heart rate 4. encourage relaxation and breathing techniques between contractions

2 Rationale: fetal bradycardia between contractions may indicate the need for immediate medical management. the nurse would immediately contact the RN, who would then contact the HCP

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. monitor the urinary output 2. monitor the maternal pulse 3. turn the client onto her side 4. monitor the maternal blood pressure

3 Rationale: with a pregnant client who is in shock, the nurse would want to increase perfusion to the placenta. a simple way to do this that requires no equipment is to turn the mother on her side. this would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. the nurse would immediately contact the RN, who would then contact the HCP.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of what condition? 1. uterine atony 2. placenta previa 3. abruptio placentae 4. placental separation

4 Rationale: 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.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1. the maneuvers measure the height of the maternal fundus 2. the maneuvers determine the lie and attitude of the fetus 3. the maneuvers are a systematic method for palpating the fetus through the maternal back 4. the maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall

4 Rationale: leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? SATA 1. uterine rigidity 2. uterine tenderness 3. severe abdominal pain 4. bright red vaginal bleeding 5. soft, relaxed, nontender uterus

4, 5 Rationale: painless bright red vaginal bleeding during the second of third trimester of pregnancy is a sign of placenta previa. the client will have a soft and relaxed nontender uterus. in clients with abruptio placentae, sever abdominal pain is present. uterine tenderness accompanies placental abruption. additionally, with abruptio placentae, the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1. leopold's maneuvers 2. a manual pelvic examination 3. hemoglobin and hematocrit evaluation 4. external electronic fetal heart rate monitoring

2 Rationale: painless vaginal bleeding is a sign of possible placenta previa. digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa becuase of the placenta filling the lower uterine segment. hemoglobin and hematocrit values help estimate the amount of blood loss. external electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia

The nurse is caring for a client who is in labor. The nurse rechecks the clients blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. squatting 2. side lying 3. tailor sitting 4. semi fowlers

2 Rationale: pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. this can be relieved by having the woman lie on her side

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, which action should the nurse take initially? 1. estimate the fetal size 2. check pelvic adequacy 3. administer an analgesic 4. determine the maternal and fetal vital signs

4 Rationale: to evaluate a womans physical well being, her temp, pulse, resp, and blood pressure (as well as the fetal heartbeat) are checked. option 3 is incorrect because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. option 1 and 2 are incorrect. these assessments should be performed by the HCP

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1. prepare for an oxytocin infusion 2. keep the client in a side lying position 3. prepare the client for epidural anesthesia 4. encourage the client to start pushing with the contractions

2 Rationale: precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. this does not allow for the maximal reperfusion of the placenta with oxygenated blood. priority care of this client includes the promotion of fetal oxygenation. a side lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. further stimulation with oxytocin is contraindicated. there may not be enough time to administer epidural anesthesia before delivery with such quick progression. pushing with contractions is not indicated, especially with this type of labor. the controlled delivery of the fetus is essential to prevent maternal and fetal injury

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1. encourage the mother to breastfeed soon after birth 2. support the mother in her reaction to the newborn 3. tell the mother that it is important to hold the newborn 4. document a complete account of the mother's reaction in the birth record

2 Rationale: women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. to assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn

The client who is being prepared for a C section is brought to the delivery room. To maintain optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1. prone position 2. semi fowlers position 3. trendelenburg 4. supine position with a wedge under the right hip

4 Rationale: vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. the best position to prevent this would be side lying, with the uterus displaced off the abdominal vessels. positioning for abdominal surgery necessitates a supine position; however a wedge placed under the right hip provides for the displacement of the uterus. a prone or semi fowlers position is not practical for this type of abdominal surgery. trendelenburgs position places pressure from the pregnant uterus on the diaphragm and lungs, thus decreasing respiratory capacity and oxygenation