UWorld Maternity: Labor and Delivery

What nursing interventions are taken if the patient's GBS status is unkown?

If GBS status is unknown: antibiotics are typically indicated when membranes have been ruptured for ≥18 hours maternal temperature is ≥100.4 F (38 C) or gestation is <37 weeks

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate?

1) Assessing fetal HR before and after procedure 2) Checking client's temp Q2H 3) Noting characteristics of amniotic fluid 17, 30, - When assisting with an amniotomy, the nurse should assess the fetal heart rate, note the characteristics of the amniotic fluid, and assist the client to an upright position after the procedure.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?

1) Document the time the fetal head was born and dystocia maneuvers 2) Flex the client's legs back against the abdomen and apply downward pressure on the symphysis pubis 3) Request additional help from other nurses

What are late decels and when do they occur?

occur after the onset of a uterine contraction and continue beyond its end. The lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline.

Wha is fetal tachycardia?

(ie, FHR baseline >160 beats/min) may be caused by fetal anemia, maternal fever, or infection

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following?

1) Abnormal or indeterminant FHR pattern 2) PPH 3) Uterine tachysystole

When are pregnant patients tested for GBS?

35- 37 weeks

What do early decels?

uniform shape from contraction to contraction onset of the early decel is early in the contraction phase of the uterus

What is Anecephaly?

A severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are not compatible with life.

When can an epidural be given in labor?

An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. - A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes).

What is normal uterine resting tone?

<20mmHg

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor?

Applying counter pressure to the patient's sacrum during contractions - Fetal occiput posterior position may cause intense back pain during labor.

What is VEALCHOP and what does it stand for?

It helps nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings V - variable decelerations E - Early decelerations A - Accelerations L - Late decelerations C - Cord compression/prolapse, oligohydraminois H - Head compression O - okay (normal fetal oxygen) P - late decelerations Placental insufficiency

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action?

Provide encouragement and coaching in breathing techniques - The period of active labor from 8-10 cm dilation (ie, "transition") can be emotionally challenging for laboring clients. Signs of near-complete dilation include bloody show and the urge to push. - Clients should be coached in breathing techniques and should avoid pushing until fully dilated to prevent cervical trauma.

The labor and delivery charge nurse receives report on several clients. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel?

Reposition an unmedicated client who is in active labor onto a birthing ball

What are signs of uterine rupture?

Signs of uterine rupture may include: - abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

What is back labor?

The occiput posterior position is associated with intense "back labor" due to increased pressure on the maternal sacrum and may result in prolonged labor. Occiput anterior position is optimal for fetal rotation and birth. Breech presentation is associated with ineffective cervical dilation and increased risk of umbilical cord prolapse.

The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider (HCP) places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately?

Uterine resting tone baseline has increased to 45 mmHg and perineal pads are dry - If baseline uterine resting tone is elevated (normal: ≤20 mm Hg) and minimal to absent fluid return is noted, the nurse should pause the infusion and notify the health care provider immediately (Option 4).

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion?

1) Assess the uterine contraction pattern 2) Initiate continuous FHR monitoring 3) Place IV oxytocin on an electric infusion pump - Oxytocin is a high-alert medication requiring precise administration via a secondary IV line on an electronic infusion pump and frequent maternal/fetal assessment.

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate?

1) Giving IM betamethasone 2) Adminsitering IVPB penicillin 3) Initiate IV magnesium sulfate

What are findings of uterine inversion?

presents with a large, red mass protruding from the introitus.

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction?

Bishop score of 10 - The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A score >8 in nulliparous women is associated with successful induction and subsequent vaginal birth.

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first?

Obtain BP - Epidural blocks can inhibit the sympathetic nervous system, causing peripheral vasodilation leading to hypotension. Hypotensive symptoms include lightheadedness and nausea. The nurse should first assess blood pressure and then intervene (eg, IV fluids, left lateral positioning, oxygen) as appropriate.

What should the nurse do when there is a cord prolapse?

The nurse should then manually elevate the presenting fetal part off the cord, leave the hand in place, and call for help.

What are findings of cervical lacerations?

suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage.

A pregnant client arrives in the emergency department by ambulance, reporting that her "water broke" at home. She is screaming and bearing down with every contraction. What questions are essential to ask in preparation for the birth and possible neonatal resuscitation?

1) How many babies are you expecting? 2) What color was the fluid when your water broke? 3) What drugs have you taken in the last 4 hours? 4) When is your due date?

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor?

1) contractions that increase in frequency 2) pain in lower back that moves to lower abdomen 3) Progressive cervical effacement

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer?

The usual and safe dose of nalbuphine hydrochloride is 10-20 mg/70 kg of body weight given intramuscularly or by IV push. The nurse should convert weight to kilograms and then calculate the dose in milliliters based on the client's body weight and using the 2 formulas: Desired dose = Prescribed amount (mg/kg) x weight (kg) Dose to administer = Desired (mg) x Quantity (mL) Available (mg)

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action?

Continue to monitor the client - An acceleration is a reassuring finding most often indicating fetal movement. Moderate variability is considered "good" and "normal" and fluctuates off baseline from 6-25/min. - An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a reassuring finding most often indicating fetal movement.

A graduate nurse is caring for a client at 39 weeks gestation who is receiving an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the electronic fetal monitoring strip, which action by the graduate nurse would cause the registered nurse to intervene?

Decreases oxytocin to 10 mU/min - Uterine tachysystole is identified when >5 contractions are present in 10 minutes averaged over 30 minutes. - Uterine tachysystole with late decelerations requires discontinuation of oxytocin, repositioning to side-lying, administration of oxygen by face mask at 8-10 L/min, and an IV fluid bolus.

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?

Donning nonsterile gloves and performing a vaginal exam with soluble gel - the student should use sterile gloves

What results in uteroplacetal insufficiency?

Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

How is oxytocin titrated?

Oxytocin is not titrated according to cervical dilation, which cannot be assessed continuously and varies among clients. - Instead, oxytocin is initiated at the lowest possible dose and titrated until contractions are 2-3 minutes apart and last for 80-90 seconds. - The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10 minutes) or fetal distress occurs.

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain?

The patient has two 18 gauge IV's and a blood type and cross match - attempted separation can result in life-threatening hemorrhage, therefore this is the priority

What do late decelerations look like?

uteroplacental insufficiency

What does a sinusoidal FHR indicate?

severe fetal anemia potentially due to fetomaternal hemorrhage (eg, abdominal trauma) or some fetal infections

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor?

1) Are contractions getting stronger? 2) Does anything you do make the pain better? 3) How frequent are contractions? 4) Where do you feel contraction pain most?

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first?

Assess for cord prolapse - Umbilical cord prolapse causes cord compression, fetal heart rate deceleration, and disruption of fetal oxygen supply. - The priority with fetal bradycardia after suspected rupture of membranes is to assess for a prolapsed cord.

A pregnant client comes to the labor and delivery unit stating, "My water just broke at home." On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate?

Assist client to knee chest position -

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?

Cessation of contractions and tachycardia - This is uterine rupture

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate?

Give medication slowly during the peak of the next contraction - Administering IV narcotics at the peak of contractions reduces the amount of narcotic that crosses the placental barrier and affects the fetus.

What are Leopold maneuvers?

It helps determine the "lie" or position of the baby. 1. The fundal grip 2. Lateral grip 3. Pawlick's grip 4. Pelvic grip

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate?

Pressing downward on the symphysis pubis - Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure?

Pudendal nerve block - A pudendal nerve block can provide pain relief for clients experiencing perineal pressure in the late second stage of labor. It may also be used in preparation for forceps-assisted birth or laceration repair in clients without an epidural. It does not provide relief of contraction pain.

What are interventions for late decels?

Stopping oxytocin if it is being administered Repositioning the client to the left/right side Administering oxygen by face mask Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed

What signs are indicative of a normal contraction pattern?

Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart.

More interventions for preterm labor

The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1) Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2) Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4) Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained

What is the McRobert's maneuver?

Used to manage shoulder dystocia during delivery of the infant. Maternal legs are removed from stirrups and sharply flexed upon the abdomen.

What is placenta accreta?

a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. - attempted separation can result in life-threatening hemorrhage.

What should the nurse do if there is a sinusoidal FHR?

nurse should notify the health care provider immediately, initiate intrauterine resuscitation (eg, positioning, IV fluids, oxygen), and anticipate an expedited birth.

What is a sinusoidial FHR?

pattern is characterized by repetitive, wave-like fluctuations with absent variability and no response to contractions; it is usually an ominous finding requiring immediate intervention