CH. 21 Prepu
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses "arrest of labor." The woman asks, "Why is this happening?" Which response is the best answer to this question? "Maybe your uterus is just tired and needs a rest." "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." "Maybe your baby has developed hydrocephaly and the head is too swollen." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." Explanation: Arrest of labor results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the second stage is CPD. Rest should allow the uterine contractions to be more efficient. The hormones secreted during pregnancy allow ligaments to soften so bones can shift to allow birth. Ultrasound would have previously been diagnosed prior to the onset of labor.
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. "Maybe dimming the lights or some soft music will help you relax a bit." "Let me leave you alone for a little while so you can get some rest." "I will keep you updated often on how you and your baby are doing." "Things are moving along but sometimes it can take a little longer." "I will have to stop giving you pain medicine because it is slowing your labor."
Maybe dimming the lights or some soft music will help you relax a bit." "I will keep you updated often on how you and your baby are doing." "Things are moving along but sometimes it can take a little longer." Explanation: 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.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? McDonald maneuver McGeorge maneuver McRoberts maneuver McRonald maneuver
McRoberts maneuver Explanation: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.
The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? Bradypnea Sudden shortness of breath Bradycardia Unrelieved pain
Sudden shortness of breath Explanation: Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.
Which action(s) will the nurse take when asked to apply suprapubic pressure during a birth with shoulder dystocia? Select all that apply. Apply downward pressure just above the pubic bone. Apply pressure between contractions. Apply pressure at an angle toward the face of the fetus. Apply pressure with the contractions. Apply downward pressure on the fundus of the uterus.
Apply downward pressure just above the pubic bone. Apply pressure between contractions. Apply pressure at an angle toward the face of the fetus. Explanation: Suprapubic pressure during a birth with shoulder dystocia is used to move the anterior shoulder under the pubic bone. The nurse would apply downward pressure just above the pubic bone, exert pressure at an angle toward the face of the fetus, and apply pressure between contractions. Downward pressure on the fundus of the uterus with the contractions is called fundal pressure, which is used to augment the pushing effort of the mother.
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? Late decelerations Early decelerations Variable decelerations Mild decelerations
Late decelerations Explanation: When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact. Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR).
Look for late decelerations on monitor, which is associated with fetal anoxia. Explanation: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? Use McRoberts maneuver. Use Zavanelli maneuver. Apply pressure to the fundus. Attempt to push in one of the fetus's shoulders.
Use McRoberts maneuver. Explanation: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? Uterine rupture Hypertonic uterus Placenta previa Umbilical cord compression
Uterine rupture Explanation: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.
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? administering oxytocin preparing the woman for an amniotomy encouraging the woman to assume a hands-and-knees position providing a comfortable environment with dim lighting
administering oxytocin Explanation: 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.
The nurse is assisting a primipara in the second stage of labor. The mother has been pushing now for almost 3 hours. The nurse should anticipate planning for: an operative delivery. augmentation with oxytocin. an increase in the epidural medication. a variation in pushing technique.
an operative delivery. Explanation: In the second stage of labor, allowing pushing for at least 3 hours for first births and at least 2 hours for second births is recommended prior to surgical interventions. Extra time may be given for individual circumstances, including epidural anesthesia. Increasing or decreasing the epidural medication will not help. Changes in position or variations in pushing technique are unlikely to be of benefit in facilitating a more rapid birth.
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? cesarean birth administration of oxytocin administration of morphine sulfate darkening room lights and decreasing noise and stimulation
cesarean birth Explanation: If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.
The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply. epidurals excessive analgesia multiple gestation maternal exhaustion maternal diabetes high fetal station at complete cervical dilation shoulder dystocia
epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Explanation: Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffective pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation (dilatation).
At 31 weeks' gestation, a 37-year-old client with a history of preterm birth reports cramps; vaginal pain; and a low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals the cervix is 2.1 cm long and dilated 3 to 4 cm and fetal fibronectin in cervical secretions. Which set of interactions should the nurse prepare to assist with? bed rest and hydration at home hospitalization, tocolytic, and corticosteroids an emergency cesarean birth careful monitoring of fetal movement (kick) counts
hospitalization, tocolytic, and corticosteroids Explanation: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the client and fetus are tolerating the continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allows for monitoring in a safe place if the client continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the client home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal movement (kick) counts is typically done with a postterm pregnancy.
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? genetic abnormality premature rupture of membranes preeclampsia placental abruption
placental abruption Explanation: The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? providing a comfortable environment with dim lighting administering oxytocin preparing the woman for an amniotomy encouraging the women to change positions frequently
providing a comfortable environment with dim lighting Explanation: 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 woman 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 woman in active labor suddenly sits up, clutches her chest, screams with pain, and then collapses back on the bed. The RN notes she is unconscious and a bluish-gray color. Which interventions are considered the priority for the nurse to implement? Select all that apply. Apply oxygen mask and start oxygen at 10 L/min. Begin CPR immediately. Place stethoscope on the abdomen to verify fetal heart rate. Start oxytocin at 4 mu/min and titrate upward every 5 minutes. Call lab and request 4 units of whole blood stat.
Apply oxygen mask and start oxygen at 10 L/min. Begin CPR immediately. Explanation: Amniotic fluid embolism occurs when amniotic fluid is forced into an open maternal uterine blood sinus after a membrane rupture or partial premature separation of the placenta. The clinical picture is dramatic. The immediate management is oxygen administration by face mask or cannula. Within minutes, she will need CPR; however, CPR may be ineffective because these procedures do not relieve the pulmonary constriction. Blood still cannot circulate to the lungs. Death may occur within minutes. Taking time to listen to FHR is not the priority. Oxytocin will not help with embolism. If the woman survives and develops DIC, fibrinogen is the blood product of choice.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? Assess fetal heart sounds. Place the woman in Trendelenburg position. Administer oxygen at 10 L/min by face mask. Administer amnioinfusion.
Assess fetal heart sounds. Explanation: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.
During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed. Administer oxytocin to increase the contractions.
Assist with maneuvers. Keep time. Document events in the record. Lower the head of the bed. Explanation: The nurse will assist with the maneuvers used to facilitate birth of the shoulders. The nurse also keeps time, by calling out how much time has passed, since the head was delivered. The fetus needs to be completely birthed within 5 minutes to minimize the risk of hypoxia. Documentation of the events taking place, including the use of maneuvers and maternal and fetal response, is another nursing responsibility. The head of the bed needs to be lowered to a flat position to increase the effectiveness of McRoberts maneuver and to give the health care provider the maximum space to birth the shoulders. Oxytocin is not administered in this situation. The shoulders are stuck, and making the contractions stronger will not resolve the problem but will increase fetal distress.
A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? Explain to her that there was probably something wrong with the infant and that is why it died. Offer to take pictures and footprints of the infant once it is delivered. Call the hospital chaplain to talk to the parents. Recommend that she not hold the infant after it is delivered so as to not upset her more.
Offer to take pictures and footprints of the infant once it is delivered. Explanation: When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.
The nurse is assessing a multipara client who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize? Include a set of piper forceps when the table is prepped. Apply pressure to the client's lower back with a fisted hand. Assist with nitrazine and fern tests. Prepare to assist with external version.
Prepare to assist with external version. Explanation: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position using external version or be born via cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counterpressure applied to the lower back with a fisted hand sometimes helps the client to cope with the "back labor" that is characteristic of occiput posterior (OP) positioning.
A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? The parents continue to mourn the loss of their infant. The parents just cannot believe their perfect infant died. The parents are beginning to demonstrate positive grieving behaviors. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn.
The parents are beginning to demonstrate positive grieving behaviors. Explanation: An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able to give birth to a healthy child. Some infants will die. Outcome achievement might include the client begins positive grieving behaviors (touching, counting toes/fingers, etc.) in response to the loss of the newborn. The other statements are probably accurate but are not written as outcome statements
A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client? complications of a post-term pregnancy complications of preterm labor complications of placenta previa placental abruption (abruptio placentae)
complications of a post-term pregnancy Explanation: A post-term pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? applying suprapubic pressure against the fetal back continuing to monitor maternal and fetal status noting the space at the maternal umbilicus auscultating the fetal heart rate at the level of the umbilicus
continuing to monitor maternal and fetal status Explanation: Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.
A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? external cephalic version trial labor forceps birth vacuum extraction
external cephalic version Explanation: External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilation (dilatation) of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.
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? today at 2200 tomorrow at 0800 tomorrow at 1200 tomorrow at 1400 tomorrow at 1800
tomorrow at 1400 Explanation: 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 client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 beats/min and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? compression on the inferior vena cava amniotic embolism to the lungs undiagnosed abdominal aorta aneurysm uterine rupture
uterine rupture Explanation: If a uterus should rupture, the client experiences a sudden, severe pain during a strong labor contraction, which the client may report as a "tearing" sensation. Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an emergency. Signs of hypotensive shock begin, including a rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils from air starvation. Fetal heart sounds fade and then are absent.