Chapter 23

place a hand gently on the fetal head to guide birth.

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to: place a hand gently on the fetal head to guide birth. ask her to push with the next contraction so birth is rapid. assess blood pressure and pulse to detect placental bleeding. attach a fetal monitor to determine fetal status.

knee-chest Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? supine side-lying sitting knee-chest

respiratory Babies born after a face presentation have a great deal of facial edema and maybe purple from bruising. The infant must be observed closely for a patent airway, which is the priority. A face presentation does not affect the cardiovascular or genitourinary systems. If lipedema is severe, the newborn might need gavage feedings until the edema subsides and sucking can occur.

An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which body system does the nurse identify as a priority? respiratory genitourinary cardiovascular gastrointestinal

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. This is due to the decreased urine flow from vasodilation. Most concerning complication is seizure. Assessing and slowing the infusion rate will relieve symptoms. Primary adverse effect that require monitoring are hypotension from vasodilation which require BP reading every hour, and FHR monitoring to detect bradycardia.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: assess the rate of flow of the oxytocin infusion. administer oral orange juice for added potassium. assess her vaginally for full dilation (dilatation). instruct her to breathe in and out rapidly.

Perineal tearing The immediate risk of a precipitous delivery is perineal tearing, because the tissue does not have time to stretch naturally. Vaginal stretching has occurred as the fetus descended to the perineum. Bladder incontinence and pelvic floor relaxation are potential long-term consequences of a precipitous birth, but they are not the immediate concern.

After only 45 minutes of labor, the client feels the urge to push. She pushes once and the baby's head is visible. With the next push, the head emerges. What is the immediate risk when the head is delivered too fast? Perineal tearing incontinence Pelvic floor relaxation Vaginal stretching

assessment for hemorrhage A succenturiate placenta can be first identified with a sonogram as the placenta is composed of several lobes instead of being one structure. A danger of this type of placental formation is that a lobe may tear and remain in the uterus after delivery. Assessment for hemorrhage is most important following delivery and in the postpartum period. While the other nursing assessments are important, due to the specific situation, the most important assessment relates to hemorrhage

During a prenatal ultrasound, the client is discovered to have a succenturiate placenta. Following delivery of the fetus and placenta, which nursing assessment is most important? assessment for hemorrhage assessment for pain assessment for a thrombus assessment for shortness of breath

oxytocin Oxytocin administration may be helpful in uncoordinated labor to stimulate a more effective and consistent pattern of contractions with a better, lower resting tone. Morphine sulfate is an IV opioid for pain. Betamethasone is given to help hasten lung maturity. Terbutaline is a tocolytic medication given to stop or slow preterm labor.

During their experience in labor & delivery, a group of nursing students are observing a woman who is having uncoordinated contractions where the monitor shows some contractions close together, followed by a long period without any contractions. The nurse asks the students, "Which medication may help to stimulate a more effective, consistent pattern of contractions?" Which medication would be considered the best answer? morphine sulfate betamethasone terbutaline oxytocin

cesarean birth 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.

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

Uterine rupture 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 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

"Different fetal positions can cause prolonged labor and back pain." Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the client's question.

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse? This is just a normal part of labor." "Different fetal positions can cause prolonged labor and back pain." "Perhaps you have been in one position for too long." "Let me help you out of bed to try walking it off."

Decreased fetal oxygenation When there is a cord prolapse the cord becomes compressed, blood flow is interrupted, and there is decreased oxygen available to the fetus resulting in fetal distress. There is a slight increased risk for postbirth infection, but it is not the priority at this time. A cord prolapse does not increase the risk for placental abruption nor does it decrease the strength of uterine contractions.

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation? Decreased fetal oxygenation Increased risk for infection Increased risk for placental abruption Decreased strength of uterine contractions

McRoberts maneuver The McRoberts maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a 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.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth? positioning the woman prone McRoberts maneuver fundal pressure Lamaze position

Uterine contractions are weak and ineffective. Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem? The fetus is macrosomic. The mother is fighting the contractions. The mother has a small pelvic opening. Uterine contractions are weak and ineffective.

Respiratory depression, hypotension, absent tendon reflexes Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other options are incorrect indications of magnesium sulfate toxicity.

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? Low potassium or elevated glucose, tachycardia, chest pain Respiratory depression, hypotension, absent tendon reflexes Severe lower back pain, leg cramps, sweating Pain in the abdomen, shoulder, or back

ruptured membranes The risk for infection increases during prolonged labor particularly in association with ruptured membranes. The other options do not increase the risk of infection during labor

A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor? multiple births ruptured membranes age of mother number of previous pregnancies

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left (LOT) or right occiput transverse (ROT) position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation? face and brow presentation breech presentation occiput posterior presentation normal presentation

Use a port closest to the client for the oxytocin infusion. When administering oxytocin, the infusion should be "piggybacked" to a maintenance IV solution and add the piggyback to the main infusion at the port closest to the client. If the oxytocin needs to be discontinued quickly during the induction, and solution remains in the tubing to still infuse, and the main IV line can still be maintained. Oxytocin is not administered as an intravenous bolus nor initial intramuscular injection. Oxytocin is not diluted in the main intravenous fluid.

A pregnant client is prescribed to have labor induced with oxytocin. The nurse is preparing to administer the medication. Which action is appropriate? Prepare a syringe with a bolus dose of medication. Give the initial dose as an intramuscular injection. Use a port closest to the client for the oxytocin infusion. Add the oxytocin to the prescribed Ringer's lactate main infusion.

precipitate labor A precipitate labor can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. It is defined as labor that takes less than 3 hours from the start of contractions to birth. Labor dystocia refers to lack of progression and there are two types: protraction and arrest. Uterine dysfunction refers to types of uterine contractions and are labeled as either hypertonic or hypotonic.

A pregnant client presents to the emergency department reporting back-toback contractions. Within 2 hours, the client is completely effaced and 9 cm dilated, and the fetal head is showing. Within minutes the client gives birth with only the nurse in attendance. This is an example of which occurrence? labor dystocia precipitate labor uterine dysfunction protraction disorder

umbilical cord prolapse. Because the client is not in labor, this development is considered premature rupture of membranes. The sudden onset of deep variable decelerations may indicate umbilical cord prolapse, which is an obstetric emergency that requires immediate intervention.

A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. The nurse should immediately check the client for: amniotic fluid infection. amniotic fluid embolus. umbilical cord prolapse. placental abruption (abruptio placentae).

Premature separation of placenta A short umbilical cord may predispose to premature separation of placenta. Cephalopelvic disproportion is not a result of a short umbilical cord. Labor is seldom affected by the length of cord. Macrosomia occurs with women who have diabetes or developed gestational diabetes.

A short umbilical cord may lead to: Cephalopelvic disproportion Preterm Labor Premature separation of placenta Macrosomia

"This is meconium-stained fluid from the baby." Green-tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called meconium-stained fluid. This is more typical in a postdate pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide? "Amniotic fluid is normally green." "This is meconium-stained fluid from the baby." "You have an infection and need antibiotics." "Green might be a yeast infection and we need to culture the discharge."

cephalohematoma Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalohematoma, and caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? asphyxia clavicular fracture cephalohematoma central nervous system injury

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." 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 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."

uterine rupture If a uterus should rupture, the woman experiences a sudden, severe pain during a strong labor contraction, which she may report as a "tearing" sensation. Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate 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. Managements include IV therapy for fluid replacement, IV oxytocin to promote contraction and stop bleeding, and emergency laparotomy to control bleeding birth the fetus.

A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm 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 an amniotic embolism to the lungs an undiagnosed abdominal aorta aneurysm uterine rupture

oxytocin, a posterior pituitary hormone Uterine contractions are the basic force that moves the fetus through the birth canal. They occur because of the interplay of a contractile and the influence of major electrolytes such as calcium, sodium, and potassium, specific contractile proteins (actin and myosin), and several hormones including oxytocin (a posterior pituitary hormone), estrogen, progesterone, and prostaglandins. The other hormones listed do not help with the force of uterine contractions.

A woman in labor for over 12 hours has made very little progress. The health care provider thinks that her contractions lack the force needed to propel the infant downward through the birth canal. The provider asks a group of nursing students which hormone may need to be given to increase the force of the contraction. Which hormone would be the best answer? antidiuretic hormone, a posterior pituitary hormone oxytocin, a posterior pituitary hormone luteinizing hormone, an anterior pituitary hormone growth hormone, an anterior pituitary hormone

uterine stimulants For dysfunctional labor (hypotonic uterine dysfunction), a uterine stimulant such as oxytocin may be prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

A woman in labor is experiencing dysfunctional labor (hypotonic uterine dysfunction). Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? sedatives tocolytics uterine stimulants corticosteroids

Look for late decelerations on monitor, which is associated with fetal anoxia. 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.

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).

Turn off the oxytocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? Increase the oxytocin. Turn off the oxytocin. Increase the methotrexate. Turn off the methotrexate.

amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? placental separation aspiration amniotic fluid embolism congestive heart failure

Altered fetal cerebral blood flow Early decelerations are the fetus's response to fetal head compression. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

The nurse caring for the laboring woman should understand that early decelerations are caused by: Altered fetal cerebral blood flow Umbilical cord compression Uteroplacental insufficiency Spontaneous rupture of membranes

Prepare the client for a cesarean birth. If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? Administer an analgesic to the client. Prepare the client for a cesarean birth. Prepare for a precipitous vaginal birth. Prepare to assist the care provider with an amniotomy.

caput succedaneum 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.

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

Use McRoberts maneuver. 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.

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.

erratic. Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? well coordinated. poor in quality. brief. erratic.

shortened A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? posterior position firm closed shortened

Congenital Heart Disease If the newborn is observed to have one umbilical artery, congenital heart anomaly should be suspected. Battledore placenta is an anomaly of the placenta that refers to the cord that is inserted marginally rather than centrally. Rheumatic heart disease is not associated with a single umbilical artery. Liver disease is not associated with only one umbilical artery.

The nurse observed that a newborn has only one umbilical artery. What condition is associated with this condition? Battledore Placenta Congenital Heart Disease Rheumatic Heart Disease Liver Disease

macrosomia Macrosomia, in which a newborn weighs 4,000 to 5,000 grams (8.8 to 11 lb) or more at birth, complicates approximately 10% of all pregnancies. Usual cause for this is gestational diabetes. Meconium is the first stool passed by a newborn. Hydrocephalus is a build-up of fluid inside the skull.

What terminology would the nurse use to document a newborn who weighs 4,000 grams (8.8 lb) or more at birth? microsomia macrosomia meconium hydrocephalus

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: increased risk for uterine rupture. potential lacerations and bleeding. increased risk for cord entanglement. damage to the maternal tissues.

Provide ongoing communication about what is happening. Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? Hold all explanations until after the birth to conserve the woman's energy. Limit discussing things the woman asks questions about. Provide ongoing communication about what is happening. Tell her not to feel anxious or discouraged about what is happening.

Sudden painless bleeding. Sudden painless bleeding is associated with vasa previa. A single umbilical artery occurs in a two-vessel cord. A short umbilical cord happens in a woman with an unusual cord length. When the fetal side of the placenta is covered by chorion, it refers to placenta circumvallata.

Which of the following is a sign of vasa previa? A single umbilical artery. Sudden painless bleeding. A short umbilical cord. The fetal side of the placenta is covered by chorion.

Two Vessel cord A two-vessel cord is an anomaly of the cord. Vasa previa is an anomaly of the placenta. Placenta circumvallata is an anomaly of the placenta. Placenta succenturiata is an anomaly of the placenta.

Which of the following is not an anomaly of the placenta? Vasa previa Two Vessel cord Placenta circumvallata Placenta succenturiata