High Risk Intrapartal Period
Following the occurrence of several cesarean sections, the charge nurse is reviewing the blood loss on four clients. What is the expected maximum value of blood loss for a client who underwent a cesarean section? 750 mL 825 mL 950 mL 1000 mL
1000 mL Rationale: The maximum amount of blood loss for a c-section client is 1000 mL.
Vacuum-assisted birth
Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head
Causes of Fetal Dystocia
Caused by excessive fetal size, malpresentation of fetus, multifetal pregnancy, or other fetal abnormalities
The physician is preparing to use forceps to assist a woman with a vaginal delivery. Which risk to the newborn would the nurse watch for? Hypoglycemia Sepsis Cephalohematoma Fractured clavicle
Cephalohematoma Rationale: Bruising or cephalohematoma is a risk with an operative vaginal delivery.
Dystocia
Defined as a "difficult labor" and the most common reason for cesarean delivery
precipitous labor and birth
Delivery of the fetus within less than 3 hours of commencement of regular contractions/active labor.
A gravid patient is undergoing induction of labor with oxytocin. The nurse assesses the uterine contractions and notes that there are six contractions in 10 minutes, and the FHR is abnormal. Which is the priority nursing action?
Discontinue oxytocin. Rationale: Due to tachysystole and abnormal FHR, oxytocin should be discontinued immediately.
While preparing a client for an emergency cesarean section, the nurse places an oxygen mask on the client. What is the rationale for this nursing intervention? Prevent hypertension Prevent tachypnea Decrease anxiety Fetal intolerance to labor
Fetal intolerance to labor Rationale: A common indication for c-section is fetal intolerance to labor, and when that occurs, oxygen is utilized to assist the fetus.
Shoulder Dystocia
Fetal shoulders can become impacted under the maternal symphysis pubis.
Breech presentations
Frank Complete Single Double Footling
Risk factors for precipitous labor
History of precipitous labor Grand multiparity
GBS treatment
IVIG or plasmapheresis
Amnioinfusion
Infusion of a sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression; may also be done to dilute meconium in amniotic fluid and reduce the risk that the infant will aspirate thick meconium at birth.
Mechanical cervical ripening
Laminaria (prostaglandin), Cervidil (Dinoprostone), *Misoprostal (Cytotec) softens and dilates the cervix. (*Risk of uterine tachysystole) Foley balloon catheter, 30-50mL water Stripping or sweeping, chorion and/or amnion membranes
Nursing Management of Post-Term Pregnancy Labor
assist with fetal surveillance; decision for labor induction; support; education, intrapartal care
GBS test
at 35-37 weeks gestation
Augmentation
enhancing/strengthen the presence of uterine contractions (Pitosin)
Nursing Assessment of Post-Term Pregnancy Labor
estimated date of birth; daily fetal movement counts, non-stress tests twice weekly, amniotic fluid analysis, weekly cervical examinations
Dystocia and ___________________ are both used to characterize an abnormally long labor.
failure to progress
Tachysystole
more than 5 contractions in 10 minutes
The nurse is preparing a client in the operating room for a cesarean section. The client asks the nurse why a roll is being placed under the hip. How should the nurse respond? "The hip tilt position allows the provider easier access to the uterus for delivery." "The hip tilt position eases pressure on the inferior vena cava and decreases the risk of hypotension." "The hip tilt position decreases bladder distention and reduces the risk of bladder injury during surgery." "The hip tilt position allows for a quicker delivery of the infant during the c-section."
"The hip tilt position eases pressure on the inferior vena cava and decreases the risk of hypotension." Rationale: The hip tilt position is utilized to decrease the pressure on the inferior vena cava, reducing maternal hypotension and subsequent fetal intolerance. While other benefits may result from this position, they are not the reasoning for such.
Following completion of four deliveries via cesarean section, the nurse states in shift report the APGAR scores for the four newborns. Which infant does the oncoming nurse see first? APGAR 5, APGAR 7 APGAR 8, APGAR 8 APGAR 9, APGAR 10 APGAR 7, APGAR 9
APGAR 5, APGAR 7 Rationale: APGAR scores are expected to be 7 or above at one and five minutes following delivery, unless there is fetal intolerance to labor prior to delivery.
The nurse is preparing a client for a cesarean section who is scheduled for 0900. What time will the nurse administer cefazolin? 07:30 08:55 08:00 07:00
08:00 Rationale: Prophylactic antibiotics should be administered one hour before the time of the c-section.
When an emergency cesarean section is required a guideline is set for a time frame surrounding the decision time to the incision time. The nurse explains to the client the guidelines for time to optimize fetal outcomes. What timeframe does the nurse share with the client? 60 minutes 45 minutes 30 minutes 15 minutes
30 minutes Rationale: The guidelines for decision to incision are 30 minutes.
Group B Streptococcus (GBS)
A common bacterium found in the vagina and rectum of healthy women. However, an infant infected with GBS can develop septicimena, pneumonia, or meningitis.
Umbilical cord prolapse
An obstetric emergency, partial or total occlusion of cord with rapid fetal deterioration
While caring for a client and family the day of a cesarean section, which considerations can be implemented by the nurse to decrease the anxiety level for all? Select all that apply. Answer any questions that the client and family may have during the day. Be sure to have the charge nurse come speak with the family. Discuss what to expect in the operating room. The same nurse should care for the client throughout the shift. Give the client an anti-anxiety medication to decrease the anxiety level.
Answer any questions that the client and family may have during the day. Rationale: Answering questions about the upcoming procedure and the recovery process can decrease fear and anxiety. Discuss what to expect in the operating room. Rationale: Allowing the partner to obtain information about the operating room and what it will be like helps to reassure the client and family as well. The same nurse should care for the client throughout the shift. Rationale: Maintaining consistency in nursing care can ease anxiety for the client.
The labor nurse is performing a vaginal exam on a patient whose membranes just ruptured spontaneously. The nurse feels a loop of umbilical cord in the vagina. Which nursing action has the highest priority? Lift the presenting part off the umbilical cord. Administer oxygen via face mask. Discontinue oxytocin infusion. Give an IV fluid bolus of 300 cc.
Lift the presenting part off the umbilical cord. Rationale: This is the highest priority because it will relieve occlusion of the cord.
bicornuate uterus
Malformed uterus having two horns; heart-shaped womb
The nurse is caring for a gravid patient in labor who is 7 cm dilated and experiencing slow labor progress. Which factors can contribute to labor dystocia? Select all that apply.
Maternal exhaustion or fear Rationale: Catecholamine release interferes with uterine contractility. Hypertonic uterine dysfunction (tachysystole) Rationale: Hypertonic contractions are weak and ineffective. Analgesia early in labor Rationale: Analgesia or anesthesia given in early labor can decrease uterine contractility.
Malpresentations of the fetus
Occiput posterior Face presentation Brow presentation Shoulder presentation Breech presentations
A laboring woman was just assessed by the nurse and found to be 8 cm dilated. She calls the nurse back in the room, stating, "I feel pressure, and I think the baby is coming." Which nursing action has the highest priority?
Perform a cervical exam. Rationale: Assessing cervical dilation and station will help determine if birth is imminent. Assist her to the bathroom to relieve her bowels. Rationale: Rectal pressure may be caused by the fetus descending further in the vagina.
A patient had an operative vaginal delivery with forceps. Which maternal complications would the nurse assess for? Select all that apply. Perineal hematoma Cesarean incision infection Hemorrhage Urinary retention Hyperreflexia
Perineal hematoma Rationale: There is an increased risk of hematoma with an operative vaginal delivery. Hemorrhage Rationale: There is an increased risk of uterine atony with an operative vaginal delivery, thus increasing the risk of postpartum hemorrhage. Urinary retention Rationale: There is a risk of bladder trauma with a forceps delivery, which could cause urinary retention.
The nurse is caring for a gravid patient who was admitted for cervical ripening prior to her induction of labor. Which statements are correct regarding cervical ripening agents? Select all that apply. Misoprostol (Cytotec) dose of 800 mcg should be given every 3 to 6 hours. Prostaglandins should be avoided in women with prior uterine surgeries. A balloon catheter is a mechanical method of cervical ripening and is an option in women with prior uterine incision. Cervidil (Dinoprostone) can be removed quickly if tachysystole occurs. Misoprostol (Cytotec) is inserted in the vaginal fornix.
Prostaglandins should be avoided in women with prior uterine surgeries. Rationale: There is increased risk of uterine rupture with prior uterine incisions, and prostaglandins are contraindicated. A balloon catheter is a mechanical method of cervical ripening and is an option in women with prior uterine incision. Rationale: This method of cervical ripening can be used when there are contraindications for pharmacologic agents. Cervidil (Dinoprostone) can be removed quickly if tachysystole occurs. Rationale: Cervidil is a vaginal insert with a string for easy removal. Misoprostol (Cytotec) is inserted in the vaginal fornix. Rationale: The vaginal route is more effective than the oral route for administration.
Risks of assisted births
Risk of tissue trauma to mother and newborn Cephalohematoma to newborn head
Bishop's Score
Scoring system for determining whether or not induction of labor will be successful, based on 5 criteria (scored from 0-3): position, cervical consistency, degree of effacement, dilatation, and station; score >8 suggests that induction will be successful.
The nurse is preparing to administer an oxytocin infusion for labor induction for a patient who is post-term. Which of the following are true regarding oxytocin for induction of labor? Select all that apply.
The dose is increased by 1 to 2 mU/min every 30 to 60 minutes, until adequate labor progress is achieved. Rationale: This is the recommended dosing schedule. Tachysystole is a potential side effect. Rationale: Tachysystole is the primary complication of oxytocin in labor. Water intoxication can occur. Rationale: This is a potential side effect with high concentrations of oxytocin with large quantities of hypotonic solutions.
Hypotonic Uterine Dysfunction
The pressure (frequency, strength and duration) of uterine contractions is insufficient and do not dilate or efface the cervix.
Forceps-assisted birth
This type of assisted birth is using an instrument with two curved spoon like blades to assist in the delivery of the fetal head
TOLAC
Trial Of Labor After Cesarean may fail or result in a vaginal delivery
cephalopelvic disproportion
condition preventing normal delivery through the birth canal; either the baby's head is too large or the birth canal is too small
Indications for Cesarean Birth
•Labor arrest •Non-reassuring fetal tracing •Malpresentation •Multiple gestation •Maternal-fetal disproportion •Macrosomia •Preeclampsia •Maternal request
atony
lack of normal muscle tone, softening
Dystocia is related to three (3) P's: Abnormalities of ___, ___, and ____.
power, passenger, passage.
Induction
preparing the cervix, stimulate/initiate the start of uterine contractions
McRoberts maneuver
suprapubic pressure applied while hyperextending the maternal legs to the chest, to assist with fetal shoulder delivery
VBAC (vaginal birth after cesarean)
vaginal birth of an infant to a woman who has had at least one previous cesarean delivery.
Cardiopulmonary resuscitation (CPR) is being performed on a gravid patient with suspected amniotic fluid embolism. The nurse knows that certain adjustments should be made during CPR on a pregnant woman. Which adjustment is recommended? Displacement of the uterus to the left side Hand placement for chest compressions slightly lower Chest compressions performed at a faster rate Bag-mask-valve ventilation instead of intubation
Displacement of the uterus to the left side Rationale: This facilitates blood return to the heart and is critical for the return of spontaneous circulation.
A gravid patient presents to labor and delivery for labor induction due to preeclampsia. The nurse notes the Bishop score of 5 in her medical record. Which intervention would the nurse anticipate? Cervical ripening agents Amniotomy Oxytocin infusion Cesarean delivery
Cervical ripening agents Rationale: A Bishop score of 6 or less denotes an unfavorable cervix, and cervical ripening is necessary prior to oxytocin induction.
Risk factors for dystocia
Congenital uterine abnormalities, such as a bicornuate uterus Malpresentation of the fetus, such as occiput posterior or face presentation Cephalopelvic disproportion Maternal fatigue and dehydration Administering early in labor, analgesia or anesthesia
During a birth, the nurse notes the fetal head retracts against the maternal perineum after delivery of the head. Which nursing actions would the nurse implement? Select all that apply. Perform McRoberts maneuver. Apply fundal pressure. Apply suprapubic pressure. Assist the provider in pulling harder on the fetal head. Request the mother not to push until directed by the provider.
During a birth, the nurse notes the fetal head retracts against the maternal perineum after delivery of the head. Which nursing actions would the nurse implement? Select all that apply. Perform McRoberts maneuver. Rationale: Flexing the thighs back against the maternal abdomen causes changes in diameter of the pelvis and helps relieve the impacted shoulder. Apply suprapubic pressure. Rationale: Applying pressure above the maternal pubic bone helps to dislodge the impacted shoulder. Request the mother not to push until directed by the provider. Rationale: The provider may be using techniques to rotate the baby, and the mother should stop pushing while this is being done.
The nurse is performing preoperative care on a client scheduled for cesarean section. Which nursing actions should be performed? Select all that apply. Insert an IV catheter Administer sodium citrate Trim pubic hair Insert straight catheter Apply sequential compression devices
Insert an IV catheter Rationale: IV fluids are given during surgery, so starting the IV before is required. Administer sodium citrate Rationale: Sodium citrate is administered before the surgery to neutralize stomach acids. Trim pubic hair Rationale: Pubic hair is trimmed to allow for better visualization of the incision site. Apply sequential compression devices Rationale: Sequential compression devices, or SCD, are used as prophylaxis for thrombosis and are applied prior to surgery.
A gravid patient with diabetes is in labor with suspected macrosomia. Which nursing actions would be done to prepare for the delivery? Select all that apply. Notify the surgical team of the potential for an operative delivery. Have an additional nurse available to assist with a shoulder dystocia. Gather neonatal supplies for a small baby. Have catheter available to empty bladder. Anticipate the need for postpartum oxytocic medications.
Notify the surgical team of the potential for an operative delivery. Rationale: Fetal macrosomia increases the risk of an operative delivery. Have an additional nurse available to assist with a shoulder dystocia. Rationale: Additional nurse may be needed to resolve a shoulder dystocia. Have catheter available to empty bladder. Rationale: Emptying the bladder makes more room for the fetus and is an intervention with a shoulder dystocia. Anticipate the need for postpartum oxytocic medications. Rationale: Macrosomia is a risk factor for postpartum hemorrhage.
To decrease the risk of bleeding following a cesarean section, the nurse administers which medication to the client following delivery of the infant? Cefozolin Oxytocin Famotidine Magnesium sulfate
Oxytocin Rationale: Oxytoxin assist the uterus to contract and decreases the risk of excessive bleeding.
There are several patients on the labor and delivery unit. Which patients are at risk for disseminated intravascular coagulation (DIC)? Select all that apply. Patient with term intrauterine fetal demise Patient with severe preeclampsia Patient with gestational diabetes Patient with twin pregnancy Patient with HELLP syndrome
Patient with term intrauterine fetal demise Rationale: A prolonged intrauterine fetal demise may lead to DIC. Patient with severe preeclampsia Rationale: Severe preeclampsia may trigger DIC. Patient with HELLP syndrome Rationale: Due to low platelet count and hemolysis with HELLP syndrome, DIC can be triggered.
The anesthesiologist reviews the blood work for a client scheduled for a cesarean section and determines that an epidural or spinal anesthesia are not possible. The nurse explains which lab result to the client as the reason for this determination? White blood cell 9.8 th/mm3 Platelet 99 th/mm3 Hemoglobin 12.7 g/dL Red blood cell 5.1 mil/mm3
Platelet 99 th/mm3 Rationale: Platelets should be above 130 th/mm3. Low platelets are a contraindication for epidural.
During a scheduled cesarean section for placenta accreta, the client required a hysterectomy due to failure of the placenta to separate. The gravida 1 para 1 client delivered a healthy baby boy. What concern does the nurse anticipate addressing with the client? Family dysfunction Postpartum psychosis Postpartum depression Ineffective bonding
Postpartum depression Rationale: Postpartum depression is a risk factor for complicated deliveries, and this client also lost the ability to bare more children, increasing the concern further.
Indications for induction or augmentation
Prolonged gestation Prolonged premature rupture of the membranes Gestational Hypertension or Diabetes Intrauterine fetal demise Maternal and partner request (25-50% of cases of labor induction)
Indications for device-assisted delivery
Prolonged second stage of labor, non-reassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, presumed fetal jeopardy or fetal distress, maternal fatigue
Nursing Management of cord prolapse
Prompt recognition Measures to relieve compression and keep cord moist
Indications for amnioinfusion
Severe variable decelerations due to cord compression Oligohydramnios due to placental insufficiency Postmaturity or rupture of membranes Preterm labor with premature rupture of membranes Thick meconium fluid
cesarean birth
Surgical birth of the fetus through an incision in the abdominal wall and uterus.
A nurse is caring for a client following a cesarean section delivery the day before. During the assessment, the nurse checks for Homan's sign. Why is the nurse conducting this assessment? There is an increased risk of thromboembolism after surgery. This assessment checks for wound healing on the surgery site. It is important to check for peripheral circulation following surgery. Constipation is a risk after a cesarean delivery.
There is an increased risk of thromboembolism after surgery. Rationale: Homan's sign looks for pain in the calf with dorsiflexion and a positive result is concerning for a deep vein thrombosis.
Hypertonic Uterine Dysfunction (Prodromal labor)
Uncoordinated uterine activity; uterine contractions are frequent an painful but do not dilate or efface the cervix.
