Chapter 23: Nursing Care of a Family Experience a Complication of Labor or Birth

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?

shortened

The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time."

The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?

"No birth is ever really dry, because amniotic fluid continues to be manufactured."

A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure?

"You'll need to stay in bed while you're having this procedure."

The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery?

Abnormal position of the fetal head

The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions?

Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min.

The nurse is monitoring a woman who is receiving oxytocin IV to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?

Discontinue the oxytocin infusion.

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?

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

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?

McRoberts maneuver

The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?

Pain relief measures

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

Put her in bed immediately, call for help, and hold the presenting part of the cord.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression.

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 are beginning to demonstrate positive grieving behaviors.

A client has been admitted to the birthing suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The primary care provider notes that the client is in hypotonic labor. What does this mean?

The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

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. For what should the nurse immediately check the patient?

Umbilical cord prolapse

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.

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?

Uterine contractions are weak and ineffective.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin

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?

cephalhematoma

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 dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

A client in the active phase of labor is diagnosed as having a protracted labor pattern. Which pattern would the nurse assess as indicative of a protracted labor pattern?

delayed descent of the fetal head

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?

fetopelvic disproportion

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

knee-chest

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?

patent airway

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding.

A nullipara woman has been in labor for 24 hours with a uterine resting tone of 25 mm Hg. A nursing student asks the preceptor, "What can be done for this woman since she is exhausted?" Which interventions would be appropriate for the nurse to share with this student? Select all that apply.

providing additional pain medication like morphine sulfate increasing IV fluid rate to maintain hydration darkening room, decreasing noise by closing the door, and encouraging rest

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention?

urine output of 20 mL/hour

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer?

uterine stimulants

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor.

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.

During a prenatal ultrasound, the client is discovered to have a placenta succenturiata. Following delivery of the fetus and placenta, which nursing assessment is most important?

Assessment for hemorrhage

A nurse is presenting an in-service program about complications that can arise during labor. The nurse determines that the teaching was successful when the group correctly chooses which findings as suggesting an amniotic fluid embolism? Select all that apply.

Sudden onset of respiratory distress Maternal hypotension Maternal tachycardia

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath

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?

Turn off the oxytocin.

There are several women in active labor on the unit. Which woman is at highest risk for developing hypotonic contractions and therefore will need frequent nursing assessments?

a G4 P3 client who is having twins and wants to experience a "natural birth"

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes

A client in week 38 of her pregnancy 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

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie

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?

uterine rupture

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?

uterine rupture

The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?

Experience of additional back pain

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

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?

erratic.

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

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments to the nursing staff. For which clients would augmentation of labor with oxytocin be considered contraindicated or used cautiously? Select all that apply.

a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours a 33-year-old female who is 32 weeks' gestation in labor with twins a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the provider

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 an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question?

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

The nurse is assessing a multipara woman 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?

Prepare to assist with external version.

A laboring woman is receiving oxytocin IV to augment her labor and 2 hours later begins having contractions every 2 minutes lasting 60 to 90 seconds each with little, if any, rest time in between the contractions. At this time, which interventions would be the priority for the nurse caring for this client? Select all that apply.

Discontinue the oxytocin infusion. Administer an IV bolus of fluids. Apply oxygen to the woman via mask at 8 to 10 L/min.

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?

Offer to take pictures and footprints of the infant once it is delivered.

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?

amniotic fluid embolism

A woman has been in active labor for over 20 hours, and the nurses are discussing this case with the health care provider. The nurses know to assess this woman for which potential complication from a prolonged labor? Select all that apply.

bleeding tendencies to the point of hemorrhage maternal postpartal infection

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum