OB Ch. 10 Assessment of High Risk Pregnancy

The nurse is caring for a patient in the first stage of labor. What maternal physiologic changes does the nurse expect? 1 Decrease in absorption of solid food 2 Increase in systolic and diastolic pressures 3 Increase in nausea and vomiting sensation 4 Increase in cardiac output by 30% to 50%

1 During the first stage of labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed down. Only systolic blood pressure increases during uterine contractions in the first stage of labor. Systolic and diastolic pressures increase during contractions in the second stage of labor and return to baseline levels between contractions. Nausea and vomiting sensations may occur during the transition from first stage to second stage of labor. In the first stage of labor, the cardiac output increases by 10% to 15%. Cardiac output increases by 30% to 50% only at the end of the first stage of labor and not in the first stage.

The nurse is caring for a patient who is in the third trimester of pregnancy. The patient reports pain in the pelvic joints. What does the nurse recognize as the cause of the pain? 1 There is relaxation of the pelvic joints. 2 There is decreased mobility of the ligaments. 3 The joint of the symphysis pubis is narrowing. 4 The pelvis may not support vaginal birth.

1 In the third trimester of pregnancy, the pelvic joints relax, leading to pain. There is increased mobility of the pelvic joints and ligaments as a result of hormonal influences. Widening of the joint of the symphysis pubis and the resulting instability may cause pain in any or all of the pelvic joints. Pain in the pelvic joints does not indicate that the pelvis may not support vaginal birth. A heart-shaped android pelvis may not support spontaneous vaginal birth.

The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? 1 It is diamond shaped in appearance. 2 It measures about 1 cm by 2 cm. 3 It closes after 6 to 8 weeks of birth. 4 It lies near the occipital bone.

1 The anterior fontanel is diamond shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm. It closes 6 to 8 weeks after birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone.

A nurse performing a vaginal examination finds that the laboring patient is 7 cm, 100% effaced, 0 station, and the fetal position is RSP. What is the nurse's priority action? 1 Notify the health care provider. 2 No action is necessary at this time. 3 Encourage the patient to ambulate. 4 Assist the patient in repositioning herself.

1 The nurse's priority action is to notify the health care provider. The acronym "RSP" stands for "right sacrum posterior," which means the fetus is on the right side of the maternal pelvis with a sacral presentation. A vaginal delivery of a fetus in a sacral presentation (breech presentation) must be avoided due to the potential of injury to the fetus during birth. This patient will require a cesarean section. Taking no action, encouraging the patient to ambulate, or assisting the patient to reposition herself will delay a safe delivery.

The nurse is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. In which phase of labor is the patient? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase

1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase, or active pushing phase, occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

The nurse is caring for a pregnant client who is in the second stage of labor. The nurse instructs the client not to hold her breath or tighten the abdominal muscles while having intense labor pain. What is the rationale for this instruction? 1 To prevent the onset of fetal hypoxia 2 To prevent maternal hypotension 3 To prevent increased fetal heart rate 4 To prevent hemorrhoids in the client

1 While caring for a client who is in the second stage of the labor, the nurse should instruct the client to refrain from performing the Valsalva maneuver. During the Valsalva maneuver, the client holds her breath and tightens the abdominal muscles, which may reduce the oxygen content in the blood and cause fetal hypoxia. Tightening of the abdominal muscles increases the intrathoracic pressure and may cause hypertension in the client, but not hypotension. Due to reduced oxygen supply, the pulse rate may decrease and cause fetal bradycardia, but not tachycardia. The pressure exerted by the fetus on the vaginal wall during the delivery causes hemorrhoids, but these are not associated with the Valsalva maneuver.

When assisting a patient in labor, the nurse expects to observe the cardinal movements that lead to the birth of the baby. Arrange the movements in the order of their occurrence. 1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. Restitution

1, 2, 3, 4, 5, 6 The cardinal movements that occur in a vertex presentation are engagement, descent, flexion, internal rotation, extension, restitution (external rotation), and finally birth by expulsion. The fetal head is said to be engaged in the pelvic inlet when the biparietal diameter of the head passes through the pelvic inlet. During descent, the presenting part progresses through the pelvis. As soon as the descending head meets resistance from the cervix or pelvic wall or pelvic floor, it undergoes flexion. The fetus flexes such that the chin is brought into closer contact with the fetal chest. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. When the fetal head reaches the perineum for birth, it undergoes extension. It is deflected anteriorly by the perineum. Restitution occurs after the head is born. It rotates briefly to the position it occupied when it was engaged in the inlet.

Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy, as the body stores up for labor 5 Uterus sinks downward and forward in first-time pregnancies.

1, 2, 3, 5 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, patients often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

The nurse is caring for a patient who had a normal vaginal birth. The patient is concerned about the shape of the infant's head. What does the nurse tell the patient? Select all that apply. 1 The bones of the skull continue to grow after birth. 2 The shape of the head undergoes molding during labor. 3 The head assumes its normal shape within a month. 4 The skull bones of an infant are generally firmly united. 5 The sutures and fontanels make the skull flexible.

1, 2, 5 The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are what? Select all that apply. 1 Passenger 2 Placenta 3 Passageway 4 Psychological response 5 Powers 6 Position

1, 3, 4, 5, 6 At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychological response.

What are the common signs that are observed in the days preceding labor? Select all that apply. 1 Persistent low backache 2 Sudden increase in lethargy 3 Blood-tinged cervical mucus 4 Increase in weight up to 1.5 kg 5 Profuse vaginal mucus

1, 3, 5 Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes. In the days preceding labor, women generally have a sudden surge of energy. They also experience a loss of 0.5 to 1.5 kg in weight. This is caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels.

What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part

1, 3, 5 Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

While assessing a newborn immediately after vaginal birth, the mother is concerned that the newborn's head has assumed an abnormal shape. What should the nurse inform the mother of the baby? Select all that apply. 1 "Your baby's head should assume a normal shape within 3 days." 2 "Our physical therapist will be able to fix the shape of your baby's head." 3 "Our experienced pediatric surgeon will need to perform surgery on your baby's head." 4 "Applying baby oil daily for 2 weeks should help normalize the shape of your baby's head." 5 "This molding of the head allowed your child to adapt to the shape of your pelvis during labor."

1, 5 A change in the shape of the newborn's head during delivery due to slight overlapping of the skull bones is called molding. The shape of the head becomes normal within 3 days. Molding allows the child's head to adapt to the shape of the mother's pelvis. Physical therapy, surgery, or application of baby oil is not required to fix the shape of the newborn's head.

The nurse is performing a vaginal examination of a pregnant patient who is in the first stage of labor. During the examination, the patient reports that she has an urge to bear down. Why does the patient feel this urge? Select all that apply. 1 The descending part of the fetus reaches the pelvic floor. 2 The presenting part of the fetus descends into the true pelvis. 3 Levels of estrogen increase and levels of progestogen decrease. 4 Levels of progestogen increase and levels of estrogen decrease. 5 Levels of oxytocin increase due to activation of stretch receptors in the vagina.

1, 5 When the presenting part of the fetus reaches the pelvic floor, it activates stretch receptors in the posterior vagina and releases endogenous oxytocin in a pregnant woman, which causes the urge bear down and push the baby out. This phenomenon is called the Ferguson reflex. The presenting part of the fetus descends into the true pelvis about 2 weeks before term; this "dropping" does not cause the urge to bear down. Levels of estrogen and progestogen do not change due to vaginal stimulation. Receptors in the vagina are activated rather than inhibited, which releases oxytocin and causes the urge to push.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. What should the nurse describe? 1 Weight gain of 1 to 3 lbs 2 Quickening 3 Fatigue and lethargy 4 Bloody show

4 Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

The nurse is assessing a pregnant client and determines that the client has a round pelvis with moderate depth, straight sidewalls, curved sacrum, and wide subpubic arch. The nurse also finds that the client's ischial spines are blunt. How should the nurse classify the client's pelvis based on these findings? 1 Android 2 Gynecoid 3 Anthropoid 4 Platypelloid

2 Based on the shape, depth, and other characteristics of the pelvis, health care providers classify it into four different types. The presence of a round pelvis with moderate depth, straight sidewalls, curved sacrum, and a wide subpubic arch indicates that the client has a gynecoid pelvis. If the client's pelvis is heart-shaped and has convergent sidewalls with a narrow subpubic arch, then it would be classified as an android pelvis. If the client's pelvis is oval with a narrow subpubic arch, then it would be classified as an anthropoid pelvis. If the client's pelvis is flat with a slightly curved sacrum, then it indicates that the client has a platypelloid pelvis.

What are the factors that enable the baby to initiate respiration immediately postpartum? 1 Fetal respiratory movements increase during labor. 2 Fetal lung fluid is cleared from the air passage. 3 Arterial carbon dioxide pressure is decreased. 4 Arterial pH and bicarbonate levels are increased.

2 Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels.

The nurse is performing the pelvic examination of a patient during the prenatal visit. Which pelvic type is least favorable for a vaginal birth? 1 Gynecoid 2 Android 3 Anthropoid 4 Platypelloid

2 The android pelvis is heart shaped and angulated. The sidewalls are convergent, the sacrum is slightly curved, and the terminal portion is often beaked. The subpubic arch is narrow, often resulting in cesarean births or difficult vaginal forceps births. It is least favorable for vaginal birth. The gynecoid pelvis is slightly ovoid or transversely rounded. The sidewalls are straight, and the sacrum is deep and curved. The subpubic arch is wide, thus enabling spontaneous vaginal births. The anthropoid pelvis is oval and wider anteroposteriorly. The sidewalls are straight, sacrum slightly curved. The subpubic arch is narrow and may result in a forceps vaginal birth. The platypelloid pelvis is flattened anteroposteriorly and wide transversely. The sidewalls are straight, the sacrum slightly curved, and the subpubic arch is wide, resulting in spontaneous vaginal birth.

When assessing a patient for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? 1 It is the part above the brim of the bony pelvis. 2 It is movable in the latter part of the pregnancy. 3 It has three planes: the inlet, midpelvis, and outlet. 4 It is ovoid and bound by the pubic arch anteriorly.

2 The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is the ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly.

Concerning the third stage of labor, of what should the nurses be aware? 1 The placenta eventually detaches itself from a flaccid uterus. 2 The duration of the third stage may be as short as 3 to 5 minutes. 3 It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. 4 The major risk for women during the third stage is a rapid heart rate.

2 The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is after birth hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

The nurse is assisting a patient in labor. What neurologic changes does the nurse expect in the laboring patient? 1 Decreased pain threshold 2 Amnesia and sedation 3 Increased perception of pain 4 Patient is elated between contractions

2 The patient experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the patient may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth.

What is the primary cause of maternal weight loss preceding labor? 1 Diarrhea 2 Water loss 3 Loss of appetite 4 Nausea and vomiting

2 The primary cause of maternal weight loss is water loss, which is responsible for a 0.5 to 1.5 kg of maternal weight loss preceding labor. Diarrhea, loss of appetite, and nausea and vomiting may precede labor but are less responsible for maternal weight loss prior to labor.

During the vaginal examination of a patient, the nurse notes that the fetus is in an oblique lie. What does this indicate? 1 The fetus cannot be born by vaginal birth. 2 The long axes of the mother and fetus are parallel. 3 The presentation is either cephalic or breech. 4 The fetal lie will undergo change during labor.

4 If the fetus is in an oblique lie, it usually converts to a longitudinal or transverse lie during labor. In an oblique lie the long axis of the fetus lies at an angle to the long axis of the mother. Fetal lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Vaginal birth cannot occur when the fetus stays in a transverse lie. In the longitudinal lie, the long axis of the fetus is parallel with the long axis of the mother. Longitudinal lies are either cephalic or breech presentations, depending on the fetal structure that first enters the mother's pelvis.

The nurse is assessing the vital signs of a patient who is in the fourth stage of labor. The nurse finds that the patient's heart rate has decreased. What would be the most probable reason for the change in heart rate during labor? 1 Cardiac arrest 2 Increased cardiac output 3 After birth hemorrhage 4 Low systolic blood pressure

2 The uterus releases blood into the maternal vascular system when it contracts during labor. This rise in the volume of blood in the maternal cardiovascular system causes increased cardiac output, leading to a decrease in heart rate. Heart rate returns to its prelabor levels within the first postpartum hour. The patient does not exhibit any signs of cardiac arrest such as shortness of breath, dizziness, or chest pain. After birth hemorrhage can cause an increase in heart rate, which is called reactive tachycardia. The blood pressure is slightly high or normal in the fourth stage of labor. Blood pressure changes in the fourth stage do not affect cardiac output.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine 2 1 cm above the ischial spine 3 at the level of the ischial spine 4 1 cm below the ischial spine

2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

The nurse assesses that a fetus is in a cephalic presentation. What does the nurse mean by the term fetal presentation? 1 The relation of the presenting part to the mother's pelvis 2 The relation of the fetus's and mother's spine 3 The part of the fetus that enters the pelvic inlet first 4 The relation of the fetal body parts to one another

3 Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero.

The nurse assisting a laboring patient recognizes the Ferguson reflex in the patient. What is the Ferguson reflex? 1 Release of endogenous oxytocin 2 Involuntary uterine contractions 3 Maternal urge to bear down 4 Mechanical stretching of the cervix

3 The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex occurs when stretch receptors in the posterior vagina cause the release of endogenous oxytocin. The involuntary uterine contractions or primary powers originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. Intrauterine pressure caused by contractions exerts pressure on the descending fetus and the cervix. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs.

The nurse assisting a patient in the second stage of labor asks the patient to avoid the Valsalva maneuver. What is the effect of the Valsalva maneuver? 1 Decreases the cardiac output 2 Decreases blood pressure 3 Causes fetal hypoxia 4 Increases the pulse rate

3 The nurse advises the patient to avoid the Valsalva maneuver for pushing during the second stageof labor, because it can result in fetal hypoxia. The Valsalva maneuver involves holding the breath and tightening the abdominal muscles. This activity increases the cardiac output and blood pressure, and the pulse rate slows down temporarily. This process is reversed when the patient takes a breath.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

During a prenatal evaluation, the nurse notes that the patient has a flat pelvis. What term does the nurse use to refer to this type of pelvis? 1 Gynecoid 2 Android 3 Anthropoid 4 Platypelloid

4 About 3% of women may have a flat pelvis, which is referred to as a platypelloid pelvis. It is flattened anteroposteriorly and wide transversely. About 50% of women have gynecoid pelvis or the classic female type of pelvis. It is slightly ovoid or transversely rounded. An android pelvis resembles the male pelvis and may be found in 23% of women. It is heart shaped or angulated. The anthropoid pelvis resembles the pelvis of anthropoid apes and may be found in 24% of women. It is oval and wider anteroposteriorly.

How does a cesarean delivery affect the transition of fetal respiration? 1 There is an increase in the bicarbonate level. 2 Fetal respiratory movements increase during birth. 3 The cesarean delivery increases the fetal oxygen (po2) pressure. 4 Fetal lung fluid may not be effectively cleared from the lung passages.

4 Fetal lung fluid may not be effectively cleared from the lung passages of a fetus born by cesarean section, affecting fetal respiration. Fluid is more effectively cleared from the lung passages as the infant passes through the birth canal during labor and a vaginal birth. The bicarbonate level is decreased in labor. Fetal respiratory movements decrease during labor as does the fetal po2 pressure.

The nurse notes that the fetus in a laboring patient is in brow presentation. What is the expected occipitomental diameter? 1 9.25 cm 2 9.5 cm 3 12.00 cm 4 13.5 cm

4 In a brow presentation, the presenting part is the mentum or chin. The occipitomental diameter is 13.5 cm at term, which is too large to permit the infant's head to enter the pelvis region of the mother. The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter. The smallest anteroposterior diameteris, the suboccipitobregmatic diameter, which is about 9.5 cm at term, is in a vertex presentation. In a sinciput presentation, theoccipitofrontal diameter is about 12.00 cm at term, with moderate extension of the head.

After a pelvic examination of a pregnant woman, the nurse concludes that the client may require a forceps-assisted delivery. What pelvic finding would support this conclusion? 1 Slightly ovoid-shaped 2 Moderate depth 3 Blunt ischial spines 4 Subpubic arch is narrow

4 The presence of a narrow subpubic arch indicates that the client has either an android pelvis or an anthropoid pelvis. In such situations, the fetus may not easily pass through the birth canal and the client may require a forceps-assisted delivery. The presence of a slightly ovoid pelvis with moderate depth and blunt ischial spines indicates a gynecoid pelvis. Women with gynecoid pelvises have wider subpubic arches, which allow the fetus to more easily pass through the birth canal. These clients may not require forceps-assisted deliveries.

Preceding labor, a pregnant patient reports a backache and increased vaginal discharge. She is also worried because she has blood-tinged cervical mucus secretions. What should the nurse do in this situation? 1 Send cervical mucus for a culture and sensitivity test. 2 Prepare the patient for induction of labor immediately. 3 Give antibiotics and other medicines to stop hemorrhage. 4 Reassure the patient by informing her that these are normal signs.

4 Preceding labor, normal signs include backache, copious brownish or blood-tinged cervical mucus secretions, and congestion of the vagina. Therefore, in this scenario, the pregnant patient needs reassurance and careful observation. Culture and sensitivity tests are not required since the patient does not show any signs of infection. The patient does not have any need for immediate induction of labor. The signs presented by the patient are not indicative of hemorrhage; therefore, no medications need to be administered.