OB Silverstri Labor and Birth at Risk
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician
ANS: 1 Rationale: when cord prolapse occurs, prompt actions are taken to relieve cord compression and increased fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm.
The nurse is monitoring a client who is in the active stage of labor the nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all the apply. 1. Age 54 years 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L
ANS: 1,23, Rationale: Age 54 years is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor.
The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the clients position frequently 4. Keeping the significant other informed of the progress of the labor
ANS: 2 Rationale: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate.
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes
ANS: 2 Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dl 4. The client is a 20 year old primigravida of average height and weight
ANS: 2 Rationale: Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Test-taking strategy: options one, three, and four are comparable or alike. They are average and normal findings. Also note that the correct option is the only option that identifies an abnormal condition
The nurse is reviewing the primary health care provider's prescriptions for a client admitted for premature rupture of the membrane. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously 2. Monitor maternal vital signs frequently 3. Perform a vaginal examination every shift 4. Administer an antibiotic per prescription and per agency protocol
ANS: 3 Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of membranes because of the risk of infection.
Fetal distress is occurring with the laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the IV flow rate 2. Continue the oxytocin drip if infusing 3. Place the client in a high Fowler's position 4. Administer oxygen, 8 to 10 L/minute, via face mask
ANS: 4 Rationale: Oxygen is administered via face mask to optimize oxygenation of the circulating blood.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent non-reassuring fetal heart rate.
ANS: 4 Rationale: Signs of fetal or maternal compromise include a persistent, non reassuring fetal heart rate, fetal acidosis, and the passage of meconium.
