Unit 2: High-risk Intrapartum 40%

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply.

Breech presentation Station -3 Transverse lie

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion?

Change in the fetal heart rate from 128 to 102 bpm

A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client?

Diarrhea and back pain

A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes?

Endocervically

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse to make at this time?

"Have you felt the baby move since the membranes broke?"

A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/ min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time?

Monitor the client's labor

A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time?

Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth

A laboring woman, who has developed an apparent amniotic fl uid embolism, is not breathing and has no pulse. In addition to calling for assistance, which of the following actions by the nurse, who is alone with the patient, is appropriate at this time?

Provide chest compressions at the depth of at least 2 inches

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate?

Provide the woman with ongoing labor support

There are four clients in the labor suite. Each client's labor is being augmented with oxytocin (Pitocin). Which of the women should the nurse monitor carefully for the potential of uterine rupture?

Age 25, G4P3003, last delivery by cesarean section

A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time?

Assess the fluid with nitrazine and see if the paper turns blue

A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman?

The baby may develop thrush after delivery

Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply.

Woman receiving oxytocin for induction Woman with meconium-stained fluid

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae?

G5 P1211, cocaine abuser

A woman, 40 2 / 7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units of oxytocin (Pitocin) to be diluted in 1,000 mL Ringer's lactate. The order reads: Administer oxytocin IV at 0.5 milliunit per min. Calculate the drip rate for the infusion pump to be programmed. Calculate to the nearest whole number.

3 mL/hr

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications?

Abruptio placentae

A woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dypsneic and cyanotic and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority?

Administer oxygen

A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take?

Check dilation and effacement

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take fi rst?

Check the fetal heart rate of a client who just ruptured membranes

Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor?

Client will exhibit normal breathing function at discharge

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fl uid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time?

Maternal temperature

A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate?

Monitor for onset of labor

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by signifi cant fetal heart bradycardia. Which of the following interventions should the nurse perform fi rst?

Turn off the oxytocin infusion

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first?

G1 P0000, 32 weeks, placental abruption, fetal heart (5 minutes ago) 120 bpm

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus (HPV). Which of the following actions by the nurse is appropriate?

Follow standard infectious disease precautions

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these fi ndings as resulting from which of the following?

Cord compression

A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations, minimal variability, and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals?

Delivery of a healthy baby

A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time?

Fetal heart rate

A client is in active labor. Which of the following assessments would warrant immediate intervention?

Fetal scalp sampling pH of 7.19

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see?

Confusion, drowsiness, and vomiting

A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following fi ndings would warrant the removal of the prostaglandin?

Contraction frequency of 1 minute

The nurse turns off the oxytocin (Pitocin) infusion after a period of tachysystole. Which of the following outcomes indicates that the nurse's action was effective?

Frequency every 3 minutes

The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take?

Increase the intravenous infusion rate

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae?

Increasing fundal height measurements

The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus?

Late decelerations

The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women?

Multigravida with late decelerations

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate?

Notify the physician of her request

A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time?

Notify the practicioner

The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order?

Primagravida with a transverse lie

Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 90 bpm with variable decelerations. A moderate amount of clear, amniotic fl uid is seen on the bed linens. The nurse concludes that which of the following has occurred?

Prolapsed cord

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform fi rst?

Put the client in the knee-chest position

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunit per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunit per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action?

The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as:

The results are equivocal, warranting further sampling

Given the fetal heart rate pattern shown below, which of the following interventions should the nurse perform first?

Turn the woman on her side

A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time?

Vaginal examination