The Point Ch. 21 Nursing Management Of Labor and Birth At Risk

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? a. nifedipine b. indomethacin c. magnesium sulfate d. betamethasone

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

A client at 32 weeks' gestation has been admitted to the labor and birth unit with preterm labor. Which medication would the nurse be likely to administer to reduce the risk of complications in the preterm newborn? a. magnesium sulfate b. nifedipine c. indomethacin d. corticosteroids

d. corticosteroids Rationale: Corticosteroids are given to help reduce or prevent the frequency and severity of respiratory distress syndrome in preterm infants delivered between 24 and 34 weeks' gestation. Medications most commonly used for tocolysis include magnesium sulfate, indomethacin, and nifedipine.

A pregnant client is experiencing dystocia resulting from persistent occiput posterior position. The client, in the first stage of labor, is reporting significant back pain. The nurse encourages the client to change positions frequently for comfort and to help promote rotation of the fetal head. Which position(s) would be appropriate for the nurse to suggest? Select all that apply. a. Modified Sims b. Squatting c. Side-lying d. Trendelenburg e. Hands and knees

b. Squatting c. Side-lying e. Hands and knees Rationale: Appropriate maternal position changes to promote fetal head rotation include hands and knees, rocking pelvis back and forth, side-lying position, side lunges during contractions, sitting, kneeling, or standing while leaning forward, and the squatting position (to give birth and enlarge the pelvic outlet). Modified Sims and Trendelenburg are appropriate for umbilical cord prolapse.

A client has arrived to the birthing center in labor, requesting a VBAC. After reading the client's previous history, the nurse anticipates that the client would be a good candidate based on which finding? a. had prior classic uterine incision b. has previous lower abdominal incision c. has contracted pelvis d. had prior transfundal uterine surgery

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

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? a. Removing the infant quickly. b. Leaving the parents alone. c. Contacting a grief counselor. d. Keeping the communication lines open.

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

The nurse is reviewing the medical record of a woman for whom induction of labor is being considered. The nurse notes the following: •Cervical dilation 4 cm •Effacement 60% •0 Station •Soft cervix •Anterior cervical position Based on this information, which Bishop score would the nurse assign? a. 12 b. 10 c. 6 d. 8

b. 10 Rationale: For each parameter listed, a score of 2 would be given, leading to a total Bishop score of 10. A score of 2 is given for cervical dilation of 3 to 4 cm, 60% to 70% effacement, -1 or 0 station, soft cervical consistency, and anterior position of the cervix. A score of 0 would be given for a closed cervix, 0% to 30% effacement, -3 station, firm cervix, and posterior position. A score of 1 would be given for cervical dilation of 1 to 2 cm, 40% to 50% effacement, -2 station, medium cervical consistency, and midposition of the cervix. A score of 3 would be given for cervical dilation of 5 to 6 cm, 80% effacement, +1 or +2 station, a very soft cervix, and anterior cervical position.

A nurse is reading a journal article about cervical ripening agents, based on the understanding that certain pharmaceuticals can be used to attain cervical ripening in women who need assistance in this area. They have also often continued into labor without further agents to stimulate uterine contractions. Which agent would the nurse anticipate reading about as an FDA-approved agent for cervical ripening? a. oxytocin b. dinoprostone c. magnesium sulfate d. misoprostol

b. dinoprostone Rationale: Dinoprostone is approved by the FDA as the only cervical ripening agent to be used; however, ACOC acknowledges the apparent safety and effectiveness of misoprostol for this purpose as well. It is contraindicated in women with prior uterine scars. It is also known to cause hyperstimulation of the uterus, which can lead to other complications. Magnesium sulfate is used in hygroscopic dilators to assist in a mechanical method of cervical dilation.

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? a. fetal buttocks as the presenting part b. contractions most forceful in the middle of uterus rather than the fundus c. reports of severe back pain d. lack of cervical dilation past 2 cm

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

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate? a. "There is no scientific evidence they work. You will just complicate your situation more." b. "Why would you do something as stupid as that?" c. "Personally, I would use them, but I cannot tell you to." d. "Please talk to your primary care provider first to ensure it is safe."

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

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: a. 3,000 g to 3500 g b. 2500 to 3000 g c. 3,500 g to 4000 g d. 4,000 g to 4500 g

d. 4,000 g to 4500 g Rationale: Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.13 to 9.15 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

A primary care provider prescribes oral tocolytic therapy for a woman with preterm labor. The nurse explains to the client about the drugs that may be used. The nurse determines that the client needs additional teaching when she states which drug might be used for oral therapy? a. nifedipine b. magnesium sulfate c. indomethacin betamethasone

b. magnesium sulfate Rationale: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone promotes fetal lung maturity by stimulating surfactant production.

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. Notify the birth attendant. b. Stop the infusion immediately. c. Slow the oxytocin infusion to the initial rate. d. Continue to monitor contractions and fetal heart rate.

b. Stop the infusion immediately. Rationale: 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.

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? a. encouraging the woman to assume a hands-and-knees position b. administering oxytocin c. preparing the woman for an amniotomy d. providing a comfortable environment with dim lighting

b. administering oxytocin Rationale: Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

A client at 33 weeks' gestation is calling the office with various reports and is very concerned. The nurse recognizes which report(s) as indicating the client is potentially going into preterm labor? Select all that apply. a. irregular contractions b. low, dull backache c. achiness in the thighs d. general sense of discomfort e. GI upset (nausea, vomiting, diarrhea)

b. low, dull backache c. achiness in the thighs d. general sense of discomfort e. GI upset (nausea, vomiting, diarrhea) Rationale: There are various subtle symptoms of preterm labor that a woman may experience. They include change or increase in vaginal discharge; pelvic pressure; low, dull backache; menstrual-like cramps; feeling of pelvic pressure or fullness; GI upset; general sense of discomfort or unease; heaviness or aching in the thighs; uterine contractions, with or without pain; more than six contractions per hour; intestinal cramping, with or without diarrhea; and persistent contractions.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition? a. infection b. macrosomia c. hemorrhage d. dystocia

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

A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been ruled out. Which response(s) by the nurse would be appropriate? Select all that apply. a. "Let me leave you alone for a little while so you can get some rest." b. "I will have to stop giving you pain medicine because it is slowing your labor." c. "Things are moving along but sometimes it can take a little longer." d. "I will keep you updated often on how you and your baby are doing." e. "Maybe dimming the lights or some soft music will help you relax a bit."

c. "Things are moving along but sometimes it can take a little longer." d. "I will keep you updated often on how you and your baby are doing." e. "Maybe dimming the lights or some soft music will help you relax a bit." Rationale: The client is experiencing problems with the psyche. The nurse should provide emotional support to the client and family. Comfort measures such as dimming the lights or putting on soft music can promote relaxation and help the client's body work more effectively with the forces of labor. Keeping the client updated about her status and that of her fetus can provide reassurance and encouragement. Explanations about labor and what to expect can help empower the client and help her cope. The nurse should provide continuous presence to allay anxiety. Pain medication is needed to reduce anxiety and stress.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: a. 9 b. 6 c. 5 d. 7

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

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction? a. Maneuvers for fetal positioning b. amniotic fluid studies c. fetal dating d. Bishop scoring

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

As part of a review class for perinatal nurses, the nurse is explaining the laboratory and diagnostic tests that can be conducted to evaluate a woman's risk for preterm labor. The nurse determines that additional teaching is needed when the group identifies which test as being used? a. blood chemistry levels b. salivary estriol levels c. fetal fibronectin testing d. transvaginal ultrasound

a. blood chemistry levels Rationale: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, amniotic fluid analysis, fetal fibronectin testing, cervical length evaluation by transvaginal ultrasound, salivary estriol, and home monitoring of uterine activity to recognize preterm contractions. Blood chemistry levels will inform the primary care provider as to the condition of the mother but would not be definitive in determining preterm labor risks.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? a. caput succedaneum b. infection of episiotomy c. cervical lacerations d. perineal hematoma

a. caput succedaneum Rationale: 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 woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? a. providing a comfortable environment with dim lighting b. encouraging the women to change positions frequently c. administering oxytocin d. preparing the woman for an amniotomy

a. providing a comfortable environment with dim lighting Rationale: Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. This action is consistent with assisting a women experiencing problems with the psyche. 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. Frequent position changes would be appropriate for a woman with persistent occiput posterior position (problem with the passenger).

A 19-year-old nulliparous is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. The nurse suspects which complication? a. precipitate labor b. reduced oxygen to the fetus c. ruptured uterus d. cephalopelvic disproportion

b. reduced oxygen to the fetus Rationale: Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between contractions. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. This occurs in early labor and affects nulliparous women more than multiparous women. A ruptured uterus is a potential complication; however, hypoxia to the fetus would occur first. Cephalopelvic disproportion is usually associated with hypotonic uterine dysfunction. Precipitate labor is one that is completed in less than 3 hours from the start of contractions to birth.

A pregnant client in labor experiences a problem with the passenger related to shoulder dystocia. The health care provider is planning to relieve it with McRobert maneuver. The client asks the nurse, "What is going to happen when they try this?" Which response by the nurse would be appropriate? a. "The provider will place firm pressure on the area just above your pubic bone to unstick the shoulder." b. "You will get a medicine to increase the strength and frequency of your contractions to move things along." c. "Your thighs will be flexed and moved away from the center of your body to open things up." d. "A gel will be placed in your vagina to soften the cervix and allow the baby to move."

c. "Your thighs will be flexed and moved away from the center of your body to open things up." Rationale: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. Shoulder dystocia is a fundamentally mechanical problem. The McRoberts maneuver can reduce the severity of injuries to the mother and newborn. With the McRobert maneuver, the mother's thighs are flexed and abducted as much as possible to straighten the pelvic curve. With suprapubic pressure, light pressure is applied just above the pubic bone, pushing the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis. The newborn's head is depressed toward the mother's anus while light suprapubic pressure is applied. Cervical ripening or medicine to stimulate uterine contractions would not be appropriate with shoulder dystocia.

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? a. Fetus descends 2 cm per hour. b. Fetus descends 1 cm per hour. c. Cervix dilates 1 cm per hour. d. Cervix dilates 2 cm per hour.

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

A G3, P2 woman arrives at the birthing center stating that she has been in labor for the past 18 hours. The nurse suspects a protracted labor pattern disorder based on which finding? a. Fetal face presentation b. Poor contraction quality and intensity c. Slower than usual cervical dilation d. Incomplete relaxation of the uterus between contractions

c. Slower than usual cervical dilation Rationale: The term protracted disorders refer to a series of events including protracted active phase dilation (slower-than-normal rate of cervical dilation) and protracted descent (delayed descent of the fetal head in the active phase). A laboring woman with a slower-than-normal rate of cervical dilation is said to have a protracted labor pattern disorder. Poor contraction quality and intensity is associated with hypotonic uterine dysfunction. Incomplete uterine relaxation between contractions is associated with hypertonic uterine dysfunction. Fetal face presentation is a problem with the passenger affecting labor progress.

A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose? a. Tomorrow at 1800 b. Tomorrow at 0800 c. Tomorrow at 1400 d. Tomorrow at 1200 e. Today at 2200

c. Tomorrow at 1400 Rationale: Betamethasone is given as two intramuscular injections, given 24 hours apart. Because the woman got her first dose at 1400 today, then her second dose would be given at 1400 tomorrow. Corticosteroids given to the mother in preterm labor can help prevent or reduce the frequency and severity of respiratory distress syndrome in premature infants delivered between 24 and 34 weeks' gestation.

A nurse is administering oxytocin to a woman in labor. The nurse monitors the infusion closely and notifies the health care provider if signs and symptoms of which condition occurs? a. Fetal distress b. Hypertension c. Water intoxication d. Uterine hypotonicity

c. Water intoxication Rationale: 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.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? a. breast stimulation b. laminaria c. amniotomy d. prostaglandin

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

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

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

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time? a. Allow the couple to spend as much time as they want with their stillborn infant. b. Give the parents a lock of the infant's hair. c. Assist the family in making arrangements for their stillborn infant. d. Avoid any discussion of the situation with the couple.

d. Avoid any discussion of the situation with the couple. Rationale: 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.