OB Chap 21 Nursing Management of Labor and Birth at Risk
The nursing student demonstrates an understanding of dystocia with which of the following statements? a) "Dystocia is not diagnosed until after the delivery." b) "Dystocia is diagnosed at the start of labor." c) "Dystocia is diagnosed after labor has progressed for a time." d) "Dystocia cannot be diagnosed until just before delivery."
"Dystocia is diagnosed after labor has progressed for a time." Explanation: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the patient and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.
Which of the following would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? a) Provide ongoing communication about what is happening. b) Tell her not to feel anxious or discouraged about what is happening. c) Hold all explanations until after the birth to conserve the woman's energy. d) Limit talking to things the woman asks questions about.
Provide ongoing communication about what is happening. Correct Explanation: Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.
Labor dystocia is an abnormally progression of labor. It is the most common cause of primary caesarian delivery. When is it most common for labor dystocia to occur? a) Fourth stage of labor b) Third stage of labor c) First stage of labor d) Second stage of labor
Second stage of labor Correct Explanation: 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.
When administering oxytocin to a woman in labor, the nurse would be alert for which of the following? a) Hypertension b) Uterine hypotonicity c) Fetal distress d) Water intoxication
Water intoxication Explanation: 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.
A woman is going to have labor induced with oxytocin. Which statement below reflects the induction technique you anticipate her primary-care provider will order? a) Administer oxytocin diluted in the main intravenous fluid. b) Administer Pitocin in two divided intramuscular sites. c) Administer Pitocin in a 20 cc bolus of saline. d) Administer oxytocin diluted as a "piggyback" infusion.
Administer oxytocin diluted as a "piggyback" infusion. Correct Explanation: Pitocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.
A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is post-term and has oligohydramnios. What does this increase the risk of during delivery? a) Cord compression b) Macrosomia c) Shoulder dystocia d) Fetal hydrocephalus
Cord compression Explanation: Oligohydramnios and meconium staining of the amniotic fluid are common complications of post-term pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be delivered. 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? a) McRonald Maneuver b) McRoberts maneuver c) McGeorge maneuver d) McDonald maneuver
McRoberts maneuver Correct Explanation: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and 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.
The client is 35 weeks of gestation and is being admitted for vaginal bleeding. The patient is stable at the time of admission. The priority nursing assessment for the client is for: a) Fetal heart tones. b) Signs of shock. c) Infection. d) Uterine stabilization
Fetal heart tones. Explanation: When a patient is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. Options C and D are not a higher priority than fetal heart tones.
In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus. a) False b) True
True
The nurse who works at the local health department is preparing to give a talk on post-term pregnancies. She wants to include the fetal risks. Which of the following should she include? (Check all that apply.) a) cephalopelvic disproportion b) brachial plexus injuries c) shoulder dystocia d) macrosomia e) failure to thrive
• cephalopelvic disproportion • brachial plexus injuries • shoulder dystocia • macrosomia Correct Explanation: Fetal risks associated with a post-term pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, and cephalopelvic disproportion. Failure to thrive is more frequently associated with newborns who are of a low birth weight.
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? a) < 8 hours b) < 4 hours c) < 3 hours d) < 5 hours
< 3 hours Correct Explanation: Precipitous labor is completed in less than 3 hours.
The experienced labor and delivery nurse knows to evaluate progress in active labor by using which simple rule? a) 1/2 cm/hour for cervical dilation b) 1 cm/hour for cervical dilation c) 2 cm/hour for cervical dilation d) 1/4 cm/hour for cervical dilation
1 cm/hour for cervical dilation Correct Explanation: In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? a) A full bladder or rectum can impede fetal descent. b) If the woman has a full bladder, labor may be uncomfortable for her. c) A full rectum can cause diarrhea. d) If the woman's bladder is distended, it may rupture.
A full bladder or rectum can impede fetal descent. Explanation: 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.
What terminology would the nurse use to document a newborn who weighs 4,000 (8.13 lbs) or more at birth? a) meconia b) hydrocephalus c) macrosomia d) microsomia
macrosomia Correct Explanation: Macrosomia, in which a newborn weighs 8.13 to 9.15 lb or more at birth, complicates approximately 10% of all pregnancies. Meconium is the first stool passed by a newborn. Hydrocephalus is a buildup of fluid inside the skull.
A patient who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. The best response by the nurse would be which of the following? a) "Let me help you out of bed to try walking it off." b) "Different fetal positions can cause prolonged labor and back pain." c) "This is just a normal part of labor." d) "Perhaps you have been in one position for too long."
"Different fetal positions can cause prolonged labor and back pain." Correct Explanation: 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 patient's question.
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? a) "This is meconium-stained fluid from the baby." b) "You have an infection and need antibiotics." c) "Green might be a yeast infection and we need to culture the discharge." d) "Amniotic fluid is normally green."
"This is meconium-stained fluid from the baby." Correct Explanation: 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 post-dates 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.
A woman is to undergo labor induction. The nurse determines that the woman most likely requires cervical ripening if her Bishop score is: a) 6 b) 9 c) 5 d) 7
5 Correct Explanation: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.
Immediately after delivering a full-term infant, a patient 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 patient? a) Congestive heart failure b) Amniotic fluid embolism c) Placental separation d) Aspiration
Amniotic fluid embolism Correct Explanation: 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.
Amniotic fluid embolism is a true medical emergency. If it occurs during labor, what sign of fetal distress is usually noted? a) Arrested fetal movement b) Tachycardia c) Tachapnea d) Bradycardia
Bradycardia Explanation: In most cases, symptoms of amniotic fluid embolism occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. If she is in labor, the fetus typically demonstrates signs of fetal distress, with bradycardia occurring in most cases.
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 of the following interventions should the nurse most expect in this case? a) Administration of oxytocin b) Cesarean birth c) Darkening room lights and decreasing noise and stimulation d) Administration of morphine sulfate
Cesarean birth Correct Explanation: 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.
You assess that the fetus of a woman is in an occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others? a) Need to have the baby manually rotated. b) Necessity for vacuum extraction for delivery. c) Shorter dilatational stage of labor. d) Experience of additional back pain.
Experience of additional back pain. Correct Explanation: 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 delivery.
A placenta succenturiate is a placenta in which the cord is inserted marginally rather than centrally. a) False b) True
False Correct Explanation: In a battledore placenta, the cord is inserted marginally rather than centrally. A placenta succenturiata is a placenta that has one or more accessory lobes connected to the main placenta by blood vessels.
Tocolytic therapy will help to prevent preterm birth. a) False b) True
False Explanation: Tocolytic therapy does not typically prevent preterm birth, but instead it may delay it.
Which of the following actions could you initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position? a) Place her in a Trendelenburg position. b) Apply ice packs to her lower back. c) Massage her lower back. d) Urge her to maintain a prone position.
Massage her lower back. Correct Explanation: Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and delivery. 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 patient 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? a) Breech presentation b) Occiput posterior position c) Nongynecoid pelvis d) Fetal macrosomia
Occiput posterior position Correct Explanation: 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."
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? a) Slow the oxytocin infusion to the initial rate. b) Stop the infusion immediately. c) Continue to monitor contractions and fetal heart rate. d) Notify the birth attendant.
Stop the infusion immediately. Explanation: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.
Which of the following would be appropriate for the use of low forceps? a) The fetal scalp is visible at the introitus without spreading the labia b) The fetal head is engaged but the leading point of the skull is less than +2 c) The leading point of fetal skull is at or above station +2, not on the pelvic floor d) The fetal skull has reached the pelvic floor, with the fetal head at the perineum
The leading point of fetal skull is at or above station +2, not on the pelvic floor Correct Explanation: Low forceps are applied when the leading point of the fetal skull is at or above station +2 and not on the pelvic floor. Outlet forceps, and not low forceps, are applied when the fetal skull has reached the pelvic floor, with the fetal head at the perineum and the fetal scalp visible at the introitus without spreading the labia. Mid forceps, and not low forceps, are applied when the fetal head is engaged but the leading point of the skull is less than +2.
A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the physician informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? a) Occipitoposterior position b) Anterior fetal position c) Transverse lie d) Cephalic presentation
Transverse lie Correct Explanation: A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.
While in labor a woman with a prior history of cesarean birth complains of light-headedness and dizziness. The nurse assesses the patient 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? a) Uterine rupture b) Placentea previa c) Umbilical cord compression d) Hypertonic uterus
Uterine rupture Correct Explanation: The patient 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 patient a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, nor umbilical cord compression.
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best action would be to a) administer oral orange juice for added potassium. b) assess her vaginally for full dilation. c) assess the rate of flow of the oxytocin infusion. d) instruct her to breathe in and out rapidly.
assess the rate of flow of the oxytocin infusion. Correct Explanation: A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.
A gravida 7, para 6 woman is in the hospital only 15 minutes when she begins to deliver precipitously. The fetal head begins to deliver as you walk into the labor room. Your best action would be to a) attach a fetal monitor to determine fetal status. b) ask her to push with the next contraction so delivery is rapid. c) place a hand gently on the fetal head to guide delivery. d) assess blood pressure and pulse to detect placental bleeding.
place a hand gently on the fetal head to guide delivery. Correct Explanation: If a head is controlled as it delivers, trauma to internal vessels or to the maternal cervix is less apt to occur.
The nurse is assessing the woman who has a forceps-assisted birth for complications. Which of the following would be least likely to occur in the mother? a) Perineal hematoma b) Infection of episiotomy c) Cervical lacerations d) Caput succedaneum
Caput succedaneum Correct Explanation: 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 pregnant woman comes to the birthing center, stating she is in labor and doesn't know far along her pregnancy is because she has not had prenatal care. A physician performs an ultrasound that indicates oligohydramnios. When the patient's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this patient? a) Placental abruption b) Complications of a post-term pregnancy c) Complications of placenta previa d) Complications of preterm labor
Complications of a post-term pregnancy Correct Explanation: A post-term 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.
After an hour of administering oxytocin intravenously, you assess a woman's contractions to be 80 seconds in length. Your first action would be to a) Discontinue the oxytocin infusion. b) Increase the flow rate of the main line infusion. c) Slow the infusion to under 10 gtts per minute. d) Continue to monitor contraction duration every 2 hours.
Discontinue the oxytocin infusion. Explanation: 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 allow fetal nourishment. You would not increase the flow rate of the main line infusion or slow the infusion without the physician's order. Uterine contractions are monitored continuously.
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 of the following? a) hypertonic contractions b) precipitous labor c) hypotonic contractions d) none of the above
precipitous labor Correct Explanation: 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 woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? a) preterm labor b) normal labor c) macrosomia d) dystocia
preterm labor Correct Explanation: Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. It is not normal labor. Macrosomia is a large fetus. Dystocia is difficult or abnormal labor.
A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor? a) multiple births b) number of previous pregnancies c) age of mother d) ruptured membranes
ruptured membranes Correct Explanation: The risk for infection increases during prolonged labor particularly in association with ruptured membranes. The other options do not increase the risk of infection during labor.
A woman you are caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. Your best response would be that a) her physician will order oxytocin to strengthen contractions. b) she needs to rest because her contractions are hypertonic. c) hypotonic contractions of this kind will strengthen by themselves. d) walking around will make her contractions more regular.
she needs to rest because her contractions are hypertonic. Explanation: These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.
A physician orders oral tocolytic therapy for a woman with preterm labor. Which agent would the nurse be least likely to administer? a) Terbutaline b) Nifedipine c) Indomethacin d) Magnesium sulfate
Magnesium sulfate Correct Explanation: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Terbutaline is given intravenously during the initial period and then switched to the oral route for maintenance.
A pregnant patient at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse? a) "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." b) "It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid." c) "You may have just passed some urine. If it were amniotic fluid, there would be much more than that." d) "Go to the hospital now, because this could be very dangerous for the baby."
"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid." Correct Explanation: The practitioner will perform a speculum examination, looking for pooling of amniotic fluid, and then test the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. Preterm premature rupture of membranes occurs when the rupture of the amniotic sac before the onset of labor happens in a woman who is less than 37 weeks' gestation.
A patient is 32 weeks gestation and sent home on modified bedrest for preterm labor. She is on tocolyitics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse? a) "You will not be able to have intercourse again until 6 weeks after you deliver." b) "The need to keep the infant safe should be of more concern than when to have sex." c) "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." d) "Intercourse has nothing to do with preterm labor; you can have sex with your husband."
"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." Explanation: The patient 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 gives the OK. Option A is incorrect as it may be giving misinformation to the patient. Option B does not answer the patient's question so it is incorrect. Option D also gives misinformation to the patient and is incorrect.
After teaching a class about various methods for cervical ripening, the instructor determines that the teaching was successful when the class identifies which of the following as a surgical method? a) Laminaria b) Amniotomy c) Breast stimulation d) Prostaglandin
Amniotomy Correct Explanation: 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.
Before calling the physician to notify him or her of a slow progression or an arrest of labor several assessments need to be made. What other maternal assessment do you need to make prior to calling the physician? a) Make sure the epidural medication is turned down. b) Check for a full bladder. c) Make sure the patient is lying on their left side. d) Assess vital signs every 30 minutes.
Check for a full bladder. Correct Explanation: Remember that a full bladder can interfere with the progress of labor. So be sure that the patient has emptied her bladder.
Which of the following interventions would be most important when caring for the client with breech presentation confirmed by ultrasound? a) Continuing to monitor maternal and fetal status b) Auscultating the fetal heart rate at the level of the umbilicus c) Noting the space at the maternal umbilicus d) Applying suprapubic pressure against the fetal back
Continuing to monitor maternal and fetal status Correct Explanation: 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.
A woman's nurse-midwife tells her that the woman has developed dystocia. You would explain that this term means a) High blood pressure related to difficult labor. b) Potential for placental detachment. c) Difficult or abnormal labor. d) Muscle weakness related to prolonged labor.
Difficult or abnormal labor. Correct Explanation: 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.
The nursing student doing a clinical obstetrics rotation correctly picks which of the following to label a pregnancy that continues past the end of the 42nd week of gestation? a) term pregnancy b) post-term pregnancy c) preterm pregnancy d) none of the above
post-term pregnancy Correct Explanation: A term pregnancy usually lasts 38 to 42 weeks. A post-term pregnancy continues past the end of the 42nd week of gestation. A preterm pregnancy ends before the 34th week of gestation.
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? a) Vacuum extraction b) External cephalic version c) Trial labor d) Forceps birth
External cephalic version Correct Explanation: 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 would be less likely to be used with a fetus in breech position.
A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which of the following would the nurse expect to find? a) Pre-term pregnancy b) Gestational diabetes c) Maternal rickets d) Small body size of mother
Gestational diabetes Correct Explanation: Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or post-term pregnancy. Pre-term pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet.
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? a) Early decelerations. b) Variable decelerations. c) Mild decelerations. d) Late decelerations.
Late decelerations. Explanation: 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. (less)
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 do you prepare her? a) An emergency cesarean section b) Bed rest and hydration at home c) Hospitalization, tocolytic therapy, and IM corticosteroids d) Careful monitoring of fetal kick counts
Hospitalization, tocolytic therapy, and IM corticosteroids Explanation: 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 patient in the hospital allow for monitoring and a safe place if the woman continues and delivers. Administration of corticosteroids may help to develop the lungs and prepare for early preterm delivery. Sending the woman home is contraindicated in the scenario described. An emergency cesarean section is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.
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 of the following conditions in this client? a) Uncoordinated contractions b) Hypotonic contractions c) Braxton Hicks contractions d) Hypertonic contractions
Hypotonic contractions Correct Explanation: 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 patient is 23 weeks gestation and was admitted for induction and delivery after noting the infant was an intrauterine fetal death. The patient had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death? a) Placental abruption b) Preeclampsia c) Premature rupture of membranes d) Genetic abnormality
Placental abruption Correct Explanation: 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, nor the possibility of preeclamsia.
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for which of the following? a) Potential lacerations and bleeding b) Increased risk for uterine rupture c) Damage to the maternal tissues d) Increased risk for cord entanglement
Potential lacerations and bleeding Correct Explanation: 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.
The nurse is monitoring a patient in labor who has had a previous cesarean section and is trying a vaginal birth with epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The patient reports severe pain in her abdomen and shoulder. What should the nurse prepare to do? a) Turn the patient on her left side. b) Place the patient in a knee-chest position. c) Bolus the patient with another dose of medication through the epidural. d) Prepare the patient for a cesarean section.
Prepare the patient for a cesarean section. Correct Explanation: 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 delivery.
Which intervention would be most appropriate for the woman experiencing dystocia related to problems involving the psyche? a) Preparing the woman for an amniotomy b) Administering oxytocin c) Encouraging the woman to assume a hands-and-knees position d) Providing a comfortable environment with dim lighting
Providing a comfortable environment with dim lighting Explanation: Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). 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.
Which of the following describes why hypertonic contractions tend to become very painful? a) More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other. b) The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. c) The number of uterine contractions is very low or infrequent. d) There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation.
The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Correct Explanation: Hypertonic contractions cause uterine cell anoxia, which is painful. Therefore options A, C, and D are incorrect.
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would you do for a patient who is in hypertonic labor because of oxytocin augmentation? a) Increase the methotrexate b) Increase the pitocin c) Turn off the pitocin d) Turn off the methotrexate
Turn off the pitocin Correct Explanation: Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.
A woman experiences an amniotic fluid embolism as the placenta is delivered. Your first action would be to a) administer oxygen by mask. b) increase her intravenous fluid infusion rate. c) put firm pressure on the fundus of her uterus. d) tell the woman to take short, catchy breaths.
administer oxygen by mask. Correct Explanation: 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 nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which of the following? a) face and brow presentation b) breech presentation c) normal presentation d) persistent occiput posterior presentation
breech presentation Correct Explanation: 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.
A nursing student correctly identifies the most desirable position to promote an easy delivery as which of the following? a) occiput anterior b) face and brow c) shoulder dystocia d) breech
occiput anterior Correct Explanation: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.
A client in labor has been diagnosed with shoulder dystocia. Which of the following risk factors would the nurse expect to assess in the client? Select all that apply. a) Post-term pregnancy b) Incompetent cervix c) Fetal macrosomia d) Maternal diabetes e) Intrauterine growth restriction
• Post-term pregnancy • Fetal macrosomia • Maternal diabetes Correct Explanation: Risk factors of shoulder dystocia include maternal diabetes, maternal obesity, post-term pregnancy, fetal macrosomia, previous history of shoulder dystocia, and multiparity. Intrauterine growth restriction and incompetent cervix are not the risks associated with shoulder dystocia. Intrauterine growth restriction is one of the factors that increase the risk of a breech presentation. Incompetent cervix is a risk factor related to preterm labor.
A client is 2 weeks past her due date, and her physician is considering whether to induce labor. Which of the following conditions must be present before induction can take place? (Select all that apply.) a) The fetus is in a longitudinal lie b) Cephalopelvic disproportion is present c) Absence of eclampsia d) The cervix is ripe e) A presenting part is engaged f) Normal maternal blood pressure
• The fetus is in a longitudinal lie • The cervix is ripe • A presenting part is engaged Correct Explanation: Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin-sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.
A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which of the following tests should the student include? (Select all that apply.) a) U/A b) arterial blood gases c) amniotic fluid analysis d) CBC e) thyroid level
• U/A • amniotic fluid analysis • CBC Correct Explanation: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.
A nurse is assessing a full-term patient in labor and determines the fetus is occiput posterior. The patient states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? a) Use a fist to apply counter pressure to the lower back. b) Apply a warm washcloth to the lower back. c) Have the physician administer a pudendal block. d) Place the patient supine with the head of bed elevated 30 degrees.
Use a fist to apply counter pressure to the lower back. Correct Explanation: 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.
The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which of the following would the nurse do to ensure a positive outcome for the client? a) Administer hydration and sedation frequently b) Turn down oxytocin administration by half c) Assess contractions by using external monitor d) Start administering tocolytic therapy
Assess contractions by using external monitor Correct Explanation: 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 of the following should the nurse do immediately to rule out prolapse of the umbilical cord in this client? a) Administer amnioinfusion b) Assess fetal heart sounds c) Administer oxygen at 10 L/min by face mask d) Place the woman in Trendelenburg position
Assess fetal heart sounds Explanation: 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.
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? a) both types can result from the split ovum b) fraternal c) neither type results from a split ovum d) identical
Identical Correct Explanation: 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 laboring patient has been pushing without delivering the fetal shoulders. The physician determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the delivery? a) Positioning the woman prone b) Fundal pressure c) Lamaze position d) McRobert's maneuver
McRobert's maneuver Correct Explanation: The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the patient 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.
Which action by the nurse would be least effective in assisting a couple who have experienced intrauterine fetal demise? a) Assist the family in making arrangements for their stillborn infant b) Refrain from discussing the situation with the couple c) Allow the couple to spend as much time as they want with their stillborn infant. d) Give the parents a lock of the infant's hair
Refrain from discussing the situation with the couple Correct Explanation: 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.
The nurse would prepare a client for amnioinfusion when which of the following occurs? a) Fetal presenting part fails to rotate fully and descend in the pelvis b) Maternal pushing is compromised due to anesthesia c) The fetus shows non-reassuring fetal heart rate patterns d) Severe variable decelerations are due to cord compression
Severe variable decelerations are due to cord compression Correct Explanation: 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, non-reassuring 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.
The nursing student doing a clinical rotation in labor and delivery has noticed numerous women expressing various emotions during labor. The student's preceptor informs the student that these emotions can lead to psychological stress, which in turn can cause which of the following complications? a) pulmonary emboli b) dystocia c) deep vein thrombosis d) premature labor
dystocia Correct Explanation: Many women experience an array of emotions during labor, which may include fear, anxiety, helplessness, desire to be alone, and weariness. These emotions can lead to psychological stress, which indirectly can cause dystocia.
You are assisting with delivery 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 deliver but instead of continuing to emerge, it retracts into the vagina. What should you try first? a) Attempt to push one of the fetus' shoulders in a clockwise or counterclockwise motion. b) McRobert's maneuver c) Apply pressure to the fundus. d) Zavanelli's maneuver
McRobert's maneuver Correct Explanation: 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 maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean delivery. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt delivery of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.
A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. You notify the physician and take what action? a) Apply pressure to the woman's lower back with a fisted hand. b) Include a set of piper forceps when you prep the table. c) Assist with Nitrazine and fern tests. d) Prepare to assist with external version or prep for a cesarean section delivery.
Prepare to assist with external version or prep for a cesarean section delivery. Correct Explanation: 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 delivered via a cesarean delivery. Piper forceps are used in the delivery 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
A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. Your institution has a policy of taking photographs of such fetuses once they are delivered. You inform the woman that pictures have been taken and ask her if she wants them; she angrily tells you no, then bursts into tears. How should you respond? a) Apologize and tell her that the photos will be destroyed immediately. b) Console her with the fact that she has other children. c) Tell her that the hospital will keep the photos for her in case she changes her mind. d) Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.
Tell her that the hospital will keep the photos for her in case she changes her mind. Correct Explanation: Emotional care of the woman is complex. The woman may need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. Option A is incorrect as there is no need to apologize to the patient. Option B is incorrect as it would be inappropriate to console her with the fact that she has other children. Option D is incorrect as it negates her feelings and is not supportive of the woman at this time.
Mrs. M. has been admitted to the delivery suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The physician notes that Mrs. M. is in hypotonic labor. What does this mean? a) The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. b) The uterine contractions may or may not be regular, but the quantity or quality or strength is sufficient to dilate the cervix. c) The uterine contractions are regular, but the quantity or quality or strength is insufficient to dilate the cervix. d) The uterine contractions are irregular, but the quantity or quality or strength is insufficient to dilate the cervix.
The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. Explanation: There are two types of uterine dysfunction: hypotonic and hypertonic. The most common is hypotonic dysfunction. This labor pattern manifests by uterine contractions that may or may not be regular, but the quantity or strength is insufficient to dilate the cervix
A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. Which of the following would the nurse identify as the problem? a) Contractions are insufficient to cause fetus descent b) Uterine contractions are too weak or uncoordinated c) Pelvis is either android type or platypelloid type d) Fetus is in a different position or presentation
Uterine contractions are too weak or uncoordinated Correct Explanation: 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 pregnant woman near term is brought to the emergency room because she's been in an automobile accident. She has sustained blunt trauma to her abdomen and has gone into labor. An epidural is started and labor is going as well as can be expected under the circumstances. Suddenly the woman complains of severe pain in her back and shoulder. What do you suspect? a) Placental abruption b) Breech presentation c) Uterine rupture d) Broken bones or torn muscles from the accident
Uterine rupture Explanation: Uterine rupture occurs when the uterus tears open, leaving the fetus and other uterine contents exposed to the peritoneal cavity. Traumatic rupture can occur in connection with a blunt trauma. Abrupt change in the fetal heart rate pattern is often the most significant sign associated with uterine rupture. Other signs are complaints of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. The scenario presented does not indicate broken bones or torn muscles from the accident, placental abruption, or a breech presentation of the fetus.
A nursing instructor is teaching students about fetal presentations during delivery. The most common cause for increased incidence of shoulder dystocia is: a) increased number of overall pregnancies b) poor quality of prenatal care c) increasing birth weight d) longer lengths of labor
increasing birth weight Correct Explanation: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births
A client in her 42nd week of pregnancy is undergoing a scheduled induction of labor based on consideration of which of the following factors? Select all that apply. a) Abnormal fetal presentation b) Gestational age c) Fetal size d) Cervical ripeness e) Complete placenta previa
• Gestational age • Fetal size • Cervical ripeness Correct Explanation: Factors that the care provider should consider when deciding if and when to induce labor include cervical ripeness, gestational age and fetal size, fetal pulmonary maturity, fetal ability to tolerate labor, uterine sensitivity to the proposed induced method, and maternal condition. The health care provider does not confirm abnormal fetal presentation and complete placenta previa when deciding to induce labor. Abnormal fetal presentation and complete placenta previa are considered contraindications to the induction of labor and not as positive factors.
The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which of the following should she include in her presentation? (Check all that apply.) a) It significantly increases the risk of C-section birth. b) It significantly increases instrumented delivery. c) It significantly increases the use of epidural analgesia. d) It significantly increases the admissions to the neonatal ICU. e) It significantly increases the weight of the newborn.
• It significantly increases the risk of C-section birth. • It significantly increases instrumented delivery. • It significantly increases the use of epidural analgesia. • It significantly increases the admissions to the neonatal ICU. Explanation: Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented delivery, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor.
The second-year nursing student taking an obstetrics course correctly attributes which of the following to the term dystocia? (Check all that apply.) a) Labor progresses normally. b) Progress of labor deviates from normal. c) Labor is fast. d) Labor is slow.
• Progress of labor deviates from normal. • Labor is slow. Explanation: Dystocia is said to exist when the progress of labor deviates from normal and is slow.
Which of the following would lead the nurse to suspect that a pregnant woman is experiencing an amniotic fluid embolism? Select all that apply. a) Tachycardia b) Sudden onset of respiratory distress c) Acute, continuous abdominal pain d) Hypotension e) Sudden onset of fetal distress
• Sudden onset of respiratory distress • Hypotension • Tachycardia Explanation: 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.
