OB 4

The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time." Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

When educating the postterm pregnant client, what should the nurse be sure to include to prevent fetal complications?

Be sure to monitor fetal movements daily. The nurse should be sure to teach the postterm client to monitor fetal movements daily.

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for? a) Location, shape, and content b) Consistency, shape, and location c) Content, lochia, place d) Consistency, location, and place

Consistency, shape, and location

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should stop breast-feeding until completing the antibiotic b) She shouldn't use analgesics because they aren't compatible with breastfeeding c) She should supplement feeding with formula until the infection resolves d) She should continue to breast-feed; mastitis won't infect the neonate

She should continue to breast-feed; mastitis won't infect the neonate

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client is nervous about taking the baby home b) The client feels empty since she delivered the neonate c) The client would like to watch the nurse give the baby her first bath d) The client would like the nurse to take her baby to the nursery so she can sleep

The client feels empty since she delivered the neonate

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position. pg 767

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine atony b) Uterine prolapse c) Uterine contraction d) Uterine subinvolution

Uterine atony

Which complication is most likely responsible for a late postpartum hemorrhage? a) Cervical laceration b) Uterine subinvolution c) Clotting deficiency d) Perineal laceration

Uterine subinvolution

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?

has previous lower abdominal incision The choice of a vaginal or repeat cesarean birth can be offered to women who had a lower abdominal incision. Contraindications to BVAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff of facility if an emergency cesarean birth is required.

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?

"Different fetal positions can cause prolonged labor and back pain." Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the client's question. pg 759

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." b) "I'll check on you in a few hours." c) "I'll contact your physician." d) "If you don't attempt to void, I'll need to catheterize you."

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a) 500 mL b) 100 mL c) 300 mL d) 250 mL

500 mL

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?

A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent. pg 759

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor more than 12 hours long. b) A planned cesarean birth. c) Labor less than 12 hours long. d) A nonelective cesarean birth.

A nonelective cesarean birth.

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse? a) Returns her son to the nursery because of fatigue. b) Absent verbalization about the birthing process. c) Cuddles her son close to her while feeding. d) Tells visitors about her son and the labor.

Absent verbalization about the birthing process.

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a) Platelet level b) Fibrinogen level c) Prothrombin time d) Activated partial thromboplastin time

Activated partial thromboplastin time

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

Anticoagulants

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems. pg 793

A nurse is caring for a client who has just undergone delivery. What is the best method for the nurse to assess this client for postpartum hemorrhage? a) By frequently assessing uterine involution b) By assessing skin turgor c) By monitoring hCG titers d) By assessing blood pressure

By frequently assessing uterine involution

A nurse is assigned to care for a 38-year-old overweight client scheduled to undergo a cesarean birth. The client is at an increased risk of thromboembolic complications. During assessment, what factor will help the nurse in the diagnosis of deep vein thrombosis of the leg? a) Dyspnea b) Calf tenderness c) Tachypnea d) Sudden chest pain

Calf tenderness

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule?

Cervix dilates 1 cm per hour. A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation. If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour b) Client maintains a urinary output greater than 30 mL per hour c) Fundus remains firm and midline with progressive descent d) Client's temperature remains below 100.4° F or 38° C orally

Client's temperature remains below 100.4° F or 38° C orally

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Episiotomy infection b) Endometritis c) Mastitis d) Subinvolution

Endometritis

Over 75% of women who give birth experience postpartum depression. a) False b) True

False

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) Her blood pressure is below 140/90. b) Her hematocrit level is over 45%. c) She can walk without experiencing dizziness. d) Her urine output is over 50 mL/h.

Her blood pressure is below 140/90.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is at the level of the umbilicus. b) Her uterus is 2 cm above the symphysis pubis. c) Her uterus is three finger widths under the umbilicus. d) She experiences "pulling" pain while breastfeeding.

Her uterus is at the level of the umbilicus.

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a) Retained placental fragments b) Prolonged labor with multiple vaginal examinations to evaluate progress c) Increased vaginal acidity leading to growth of bacteria d) Loss of protection with premature rupture of membranes

Increased vaginal acidity leading to growth of bacteria

The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which statements should she include in her presentation? Select all that apply

It significantly increases the risk of cesarean birth. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented birth, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor. pg 776

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?

Keep the communication lines open. Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye. pg 784

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Uterine atony b) Uterine inversion c) Laceration d) Hematoma

Laceration

A client has had a forceps delivery which resulted in lacerations and bleeding. How can a nurse identify if the bleeding is due to laceration? a) Look for a contracted uterus with vaginal bleeding. b) Look for a boggy uterus with vaginal bleeding. c) Look for an inverted uterus with vaginal bleeding. d) Look for a subinvoluted uterus with vaginal bleeding.

Look for a contracted uterus with vaginal bleeding.

The nurse has attempted to massage a boggy uterus to firm state without success. The next intervention the nurse should anticipate is the administration of what medication? a) Ibuprofen b) Oxytocin c) Digoxin d) Penicillin

Oxytocin

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which of the following would the nurse administer as ordered after repositioning? a) Magnesium sulfate b) Terbutaline c) Low-dose nitroglycerin d) Oxytoxic agent

Oxytoxic agent

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Pad count b) Vital signs c) Complete blood count d) Urine volume excreted

Pad count

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

Palpate her fundus.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum psychosis b) Postpartum panic disorder c) Postpartum blues d) Postpartum depression

Postpartum psychosis

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Postpartum depression b) Postpartum blues c) Maladjustment d) Postpartum psychosis

Postpartum psychosis

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth. pg 775

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following? a) Integumentary b) Reproductive c) Breast d) Urinary

Reproductive

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time

Restless and agitated, concerned with self

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include nipple piercing. b) Risk factors include breast pumps. c) Risk factors include complete emptying of the breast d) Risk factors include frequent feeding.

Risk factors include nipple piercing.

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? a) Semi-Fowler's. b) On her left side. c) Flat in bed. d) Trendelenburg.

Semi-Fowler's.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Escherichia coli b) Streptococcus pyogenes c) Group beta-hemolytic streptococci (GBS) d) Staphylococcus aureus

Staphylococcus aureus

Brenda develops mastitis 3 weeks after delivery. What part of self-care do you tell her is most important? a) To take her antibiotic medication for the full 10 days even if she begins to feel better sooner b) To breast-feed or otherwise empty her breasts every 1 to 2 hours c) To increase her fluid intake to ensure that she will continue to produce adequate milk d) To use NSAIDs, warm showers, and warm compresses to relieve her discomfort

To breast-feed or otherwise empty her breasts every 1 to 2 hours

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:

place a hand gently on the fetal head to guide birth. If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to occur.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages. pg 758

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?

tocolytic therapy Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity. pg 769

A client in her 7th week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. a) Bizarre behavior b) Inability to concentrate c) Manifestations of mania d) Loss of confidence e) Decreased interest in life

• Inability to concentrate • Loss of confidence • Decreased interest in life

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which of the following interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. a) Monitor client's vital signs b) Get a pad count c) Assess client's skin turgor d) Assess client's uterine tone e) Assess deep tendon reflexes

• Monitor client's vital signs • Get a pad count • Assess client's uterine tone

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? a) Delayed development of the newborn b) Ineffectiveness of breast-feeding c) Interference with the maternal-newborn attachment process d) Alteration in normal maternal hormonal function

Interference with the maternal-newborn attachment process

The nurse assesses the patient who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. Select the most likely cause of the signs and symptoms. a) Infection of the uterus. b) Uterine atony. c) Perineal hematoma. d) Lacerations.

Lacerations

A nurse finds that a client is bleeding excessively after a vaginal delivery. Which assessment finding would indicate retained placental fragments as a cause of bleeding? a) Firm uterus with a steady stream of brightred blood b) Large uterus with painless dark-red blood mixed with clots c) Firm uterus with trickle of bright-red blood in perineum d) Soft and boggy uterus that deviates from the midline

Large uterus with painless dark-red blood mixed with clots

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Size of the neonate b) Length of labor c) Method of delivery d) Maternal Rh status

Length of labor

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?

Leopold's maneuver Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed. Both need to be favorable for a successful induction. Leopold's maneuver is a technique for determining the position of the fetus as it moves through the labor process.

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Massaging the fundus firmly b) Administering ergonovine (Ergotrate) c) Performing bimanual compressions d) Notifying the primary health care provider

Massaging the fundus firmly

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases. pg 759

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Suggest that she take an oral analgesic b) Encourage her to drink large amounts of fluid c) Administer amoxicillin, as prescribed d) Obtain a clean-catch urine specimen

Obtain a clean-catch urine specimen

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Apply cold compresses to the breast b) Perform handwashing before breastfeeding c) Avoid frequent breastfeeding d) Avoid massaging the breast area

Perform handwashing before breastfeeding

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first? a) Seek an order to obtain and administer an oxytocic. b) Ensure that her bladder is empty. c) Place one hand over the symphysis pubis. d) Insert uterine packing to control the hemorrhage.

Place one hand over the symphysis pubis.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Maladjustment b) Postpartum blues c) Postpartum psychosis d) Postpartum depression

Postpartum psychosis

The nurse is admitting a client in labor. The care provider determines that the fetus is in a transverse lie and not responsive to Leopold's maneuvers. What intervention should the nurse provide for the client?

Prepare the client for a cesarean birth. If a transverse lie persists, the fetus cannot be born vaginally. The most common method the practitioner uses to diagnose fetal malpresentation is Leopold's maneuvers followed by ultrasound. Sometimes the practitioner notes transverse lie by looking at the contour of the abdomen, which tends to be in the shape of a football, wider side to side than top to bottom. pg 759

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth. pg 783

A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. The nurse notifies the primary care provider and takes which action?

Prepare to assist with external version or prep for a cesarean birth. Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via a cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning. pg 758

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What assessment finding will the nurse expect to find in the client? a) Prolonged bleeding time b) Postpartum fundal height that is higher than expected c) Foul-smelling vaginal discharge d) A fever of 100.4° F (38.0° C) after the first 24 hours following childbirth

Prolonged bleeding time

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do? a) Lay the patient flat and start oxygen. b) Sit the patient up 90 degrees and call the RN. c) Raise the head of the bed to at least 45 degrees. d) Start oxygen at 2 to 3 liters per minute via nasal cannula.

Raise the head of the bed to at least 45 degrees.

A couple has just experienced intrauterine fetal demise. Which action by the nurse would be least effective in assisting them?

Refrain from discussing the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time. pg 784

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient? a) Risk for infection related to microorganism invasion of episiotomy b) Risk for fatigue related to chronic bleeding due to subinvolution c) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis d) Risk for impaired breastfeeding related to development of mastitis

Risk for fatigue related to chronic bleeding due to subinvolution

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a) Uterine hyperstimulation b) Seizures c) Flushing d) Headache

Seizures

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

You are caring for a woman who is receiving IV antibiotics and supportive care for endometritis. Which of the following findings should you report as soon as you notice it? a) Breast-feeding b) Gradually decreasing temperature and pulse rate c) Steadily decreasing volume of urine d) Excessive diaphoresis

Steadily decreasing volume of urine

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) Mastitis usually develops in both breasts of a breast-feeding client b) A breast abscess is a common complication of mastitis c) The most common pathogen is group A beta-hemolytic streptococci d) Symptoms include fever, chills, malaise, and localized breast tenderness

Symptoms include fever, chills, malaise, and localized breast tenderness

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

A woman delivered a healthy baby girl two days ago. This is her third child and both of the other children are also girls. Which observation by the nurse indicates the need for additional assessment and follow-up? a) The woman comments that her baby has red hair like her grandmother. b) The woman reports that she will be happy to get home because she does not like hospital food. c) The woman actively participates in the care of her baby. d) The woman tells a friend, referring to her baby, "It just cries all the time."

The woman tells a friend, referring to her baby, "It just cries all the time."

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply.

U/A amniotic fluid analysis CBC Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis. pg 772

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli's maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

Uterine atony.

A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. What would the nurse identify as the problem?

Uterine contractions are too weak or uncoordinated. When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilatation. Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Pain in the lower abdomen c) Foul smelling lochia d) Uterine protrusion into the vagina

Uterine protrusion into the vagina

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Elevated blood pressure b) Decreased respiratory rate c) Warm and flushed skin d) Weak and rapid pulse

Weak and rapid pulse

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Wound care and hand washing b) Strict adherence to antibiotic therapy c) Proper perineal care d) Use of warm compresses and sitz baths

Wound care and hand washing

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position. pg 759

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?

amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. pg 789

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks. Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that birth is unlikely within 2 weeks following the test. It does not diagnose infection.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior. pg 759

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth If the cause of the delay in dilatation is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD. pg 775

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?

complications of a postterm pregnancy A postterm pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

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

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus. pg 767

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

A woman's nurse-midwife tells her that the woman has developed dystocia. The nurse explains that this term means:

difficult or abnormal labor. Dystocia is a general term used to describe difficult or abnormal labor. Dystocia does not indicate high blood pressure related to difficult labor, a potential for placental detachment, nor muscle weakness related to prolonged labor.

After an hour of administering oxytocin intravenously, the nurse assesses a woman's contractions to be 80 seconds in length. The nurse's first action would be to:

discontinue the oxytocin infusion. If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allows fetal nourishment

The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply.

epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffetive pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

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

increasing birth weight. Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births. pg 758

At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus?

late decelerations When the fetus is being deprived of oxygen the fetus will demonstrated late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply.

low socioeconomic status smoking high level of stress alcohol use Demographic and lifestyle risk factors associated with preterm labor are extremes of maternal age (younger than 17 years or older than 35 years), low socioeconoomic status, smoking, alcohol or drug use, high levels of stress, and long working hours. Infection and hypertension are medical risk factors and not demographic or lifestyle factors.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia are risk to the mother not the fetus.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

magnesium sulfate Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent. pg 769

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor." pg 767

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia. pg 784

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released. pg 790

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from start of contraction to birth.

A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply.

problems with the uterus problems with the fetus Labor dysfunction can occur because of problems with the uterus or fetus. Although the others might affect the type of prenatal care a woman receives, they do not directly affect her process of labor

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition?

reports of severe back pain Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

A pregnant woman has just presented to the emergency department with various reports and in distress. Which finding would lead the nurse to suspect that she is experiencing an amniotic fluid embolism? Select all that apply.

sudden onset of respiratory distress hypotension tachycardia The woman with an amniotic fluid embolism commonly reports difficulty breathing. Other signs include hypotension, tachycardia, cyanosis, seizures, coagulation difficulties, and uterine atony with subsequent hemorrhage. A sudden onset of fetal distress and acute continuous abdominal pain is associated with uterine rupture

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with premature birth would the nurse discuss with the client? Select all that apply.

uterine or cervical abnormalities current multiple gestation pregnancy history of previous preterm birth The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

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

A woman in labor is receiving oxytocin. Which effect would the nurse need to be alert for potentially occurring?

water intoxication Oxytocin can lead to water intoxication and can cause hypotension. Uterine hypertonicity is a possible adverse effect of oxytocin administration. Oxytocin does not cross the placental barrier, and no fetal problems have been observed.

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate?

"Please talk to your primary care provider first to ensure it is safe." It is important that the primary care provider knows if and when the client is using herbal supplements to ensure there will be no danger to the woman or fetus. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus none can be recommended regarding their efficacy or safety. The statement about personal use is inappropriate because the nurse should not reveal personal information. Telling the client that the herbs will complicate the situation is inappropriate because the statement is judgmental and there is no information, whether positive or negative that the herbs can be harmful. The statement about doing something stupid is demeaning to the client. pg 778

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

During labor, a woman at 41 weeks' gestation notes her amniotic fluid is leaking and is green in color. She is asking the nurse why the fluid is green. What is an appropriate response by the nurse?

"This is meconium-stained fluid from the baby." Green tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called mecnomium-stained fluid. This is more typical in a postdates pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 102.4°F (39.1°C) b) 99.6°F (37.5°C) c) 104.2°F (40.1°C) d) 100.4°F (38°C)

100.4°F (38°C)

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 250 ml. b) 1000 ml. c) 500 ml. d) 750 ml.

1000 ml.

A client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used?

2 to 7 days Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:

4,000 g or more. Macrosomia occurs when the fetus measures 4,000 g (8.13 lbs) or more at birth and complicates approximately 10% of all pregnancies. The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

Which woman should you suspect of having endometritis? a) A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. b) A woman with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. She reports severe perineal pain. The edges of the episiotomy have separated. c) An obese woman who has a temperature of 100.4 degrees at 12 hours after delivery. Her lochia is moderate; vaginal cultures are negative. d) A woman with PROM before delivery complains of severe burning with urination, malaise and severe temperature spikes on the seventh postpartum day. WBC is 21,850cells/mm3; temperature is 101 degrees; and her skin is pale and clammy.

A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

A nurse is caring for a client at 38 weeks gestation who is diagnosed with chorioamnionitis. On which intervention should the nurse place priority?

Administer oxytocin. Chorioamnionitis is an indication for labor induction. The WBC, temperature, and amniotic fluid are not priority to assess because the nurse already knows the client has chorioamnionitis.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). The nurse is correct when performing which intervention? a) Avoiding administration of oxytocics b) Administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) c) Continual firm massage of the uterus d) Administration of platelet transfusions as ordered

Administration of platelet transfusions as ordered

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? a) Assist client in performing leg exercises every two hours b) Roll a bath blanket or towel and place it firmly behind the knees c) Limit oral intake of fluids for the first 24 hours to prevent nausea d) Ambulate the client as soon as her vital signs are stable

Ambulate the client as soon as her vital signs are stable

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying warm compresses b) Restricting fluids c) Administering bromocriptine (Parlodel) d) Applying ice

Applying ice

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Assess the woman's vital signs. d) Call the woman's health care provider.

Assess the woman's fundus.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Call the woman's health care provider. b) Assess the woman's fundus. c) Assess the woman's vital signs. d) Begin an IV infusion of Ringer's lactate solution.

Assess the woman's fundus.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. c) Her perineum is obviously edematous on inspection. d) She tells you she is extremely thirsty.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching? a) Avoid iron replacement therapy b) Shortness of breath is a common adverse effect of the medication c) Wear knee-high stockings when possible d) Avoid over-the-counter (OTC) salicylates

Avoid over-the-counter (OTC) salicylates

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Refrain from performing any leg exercises b) Avoid prolonged straining during defecation c) Avoid products containing aspirin d) Sit with legs crossed over each other

Avoid products containing aspirin

A nurse is caring for a client who has been treated for a deep vein thrombosis (DVT). Which teaching point should the nurse stress when discharging the client? a) Avoid use of oral contraceptives. b) Plan long rest periods throughout the day. c) Avoid using compression stockings. d) Avoid using products containing aspirin.

Avoid use of oral contraceptives.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Degree of responsiveness, respiratory rate, fundus location b) Blood pressure, pulse, complaints of dizziness c) Attachment, lochia color, complete blood cell count d) Height, level of orientation, support systems

Blood pressure, pulse, complaints of dizziness

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient? a) Call her caregiver if amount of lochia decreases. b) Call her caregiver if lochia moves from serosa to rubra. c) Call her caregiver if lochia moves from rubra to serosa. d) Call her caregiver if lochia moves from serosa to alba.

Call her caregiver if lochia moves from serosa to rubra.

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Use semi-Fowler's position to encourage uterine drainage c) Check for bladder distention, while encouraging the client to void d) Perform vigorous fundal massage for the client

Check for bladder distention, while encouraging the client to void

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Ask her to raise her foot and draw a circle. b) Bend her knee and palpate her calf for pain. c) Blanch a toe and count the seconds it takes to color again. d) Dorsiflex her right foot and ask if she has pain in her calf.

Dorsiflex her right foot and ask if she has pain in her calf.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal? a) Klebsiella pneumoniae b) Gardenerella vaginalis c) Staphylococcus aureus d) Escherichia coli

Escherichia coli

Initial measures to stop Jessica's bleeding have not proved successful and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula; Jessica's brother suddenly says to her partner, "This is all your fault!" What is the best response by the nurse? a) Tell them that the RN will be notified, who will explain Jessica's treatment to them. b) Explain Jessica's care, focusing on any signs of improvement, while acknowledging that this is a difficult time for them. c) Leave the room quietly; this is a family matter. d) Draw the brother aside and tell him that if he can't control himself, he'll have to leave.

Explain Jessica's care, focusing on any signs of improvement, while acknowledging that this is a difficult time for them.

Two weeks after a vaginal delivery, a client presents with low-grade fever. The client also complains of a loss of appetite and low energy levels. The physician suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection? a) Apprehension and diaphoresis b) Foul-smelling vaginal discharge c) Sudden onset of shortness of breath d) Pain in the lower leg

Foul-smelling vaginal discharge

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Dehydration b) Normal vital signs c) Infection d) Shock

Infection

A full-term pregnant client is being assessed for induction of labor. Her Bishop score is less than 6. Which prescription would the nurse anticipate?

Insert a Foley catheter into the endocervical canal. A Bishop score of less than 6 indicates that a cervical ripening method should be used before inducing labor. A low Bishop score is not an indication for cesarean birth; there are several other factors that need to be considered for a cesarean birth. A Bishop score of less than 6 indicates that vaginal birth will be unsuccessful and prolonged because the duration of labor is inversely correlated with the Bishop score.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? a) Instruct the client to empty her bladder before the examination b) Wear sterile gloves when assessing the pad and perineum c) Perform the examination as quickly as possible d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus

Instruct the client to empty her bladder before the examination