Unit 2: High-risk Intrapartum 4/5
To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which type of medication?
Antacids
A woman has been in the second stage of labor for 2½ hours. The fetal head is at +4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time?
Assess the fetal heart rate after each contraction
The nurse is admitting four full-term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the healthcare practitioner for which of the clients? The client who has: Select all that apply.
Cervical cerclage Active herpes simplex 2
A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate?
Diminished short- and long-term variability
The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of?
Epidurals do not fully sedate motor nerves
The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis?
Explain all procedures slowly and carefully
A doctor orders a narcotic analgesic for a laboring client. The nurse notes that there are late decelerations on the electronic fetal monitor tracing. Which of the following situations would lead a nurse to hold the medication?
Fetal monitor tracing shows late decelerations
A pregnant woman, G3 P2002, had her two other children by cesarean section. Which of the following situations would mandate that this delivery also be by cesarean?
The previous uterine incisions were vertical
An anesthesiologist informs the nurse that a woman scheduled for cesarean section will have the procedure under general anesthesia with postoperative patientcontrolled analgesia rather than under continuous epidural infusion. Which of the following would warrant this decision?
The woman has had surgery for scoliosis
During a nurse's shift, the fetal heartbeat patterns on fi ve fully dilated clients showed minimal variability and late decelerations. The primary healthcare practitioners all requested forceps to speed the deliveries. In which of the situations should the nurse have refused to provide the delivery forceps? Select all that apply.
Transverse fetal lie Mentum presentation and -1 station
A client, G3 P2002, is immediately postexternal version. The nurse monitors this client carefully for which of the following?
Variable fetal heart decelerations
The nurse is caring for four women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? Select all that apply.
Fetus is in the left sacral posterior position Fetus has been diagnosed with meningomyelocele
A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One-half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time?
Narcan (naloxone)
A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time?
Palpate bladder
A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure?
Previous cesarean section
The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time?
Risk for impaired skin integrity
A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure?
Terbutaline (Brethine)
A woman is delivering a macrosomic baby. The midwife is performing a mediolateral episiotomy. Draw a line where the episiotomy is being performed.
Drawn episiotomy that is about 45 degrees from the midline. The direction in which the episiotomy is performed is usually dependent upon whether the practitioner is left-handed or right-handed.
A physician has given a nurse a verbal order to apply cricoid pressure. Which of the following is the likely indication for the action?
Endotracheal tube insertion
A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation?
Left mentum anterior (LMA)
A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinical fi ndings would be a candidate for an external version?
Left sacral posterior position
A woman, 32 weeks' gestation, contracting every 3 min × 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client?
Low urinary output
