LP 10 High Risk Intrapartum

43. A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.

1. A fetal heart check is the appropriate assessment. TEST-TAKING TIP: The clinical scenario is indicative of a placental abruption. Since the only oxygenation available to the fetus is via the placenta, the appropriate action by the nurse at this time is to determine the well-being of the fetus.

47. A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 millunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1. An order for oxytocin administration should be questioned. TEST-TAKING TIP: Since the stem states that this woman has symptomatic placenta previa, the test taker can conclude that the woman is bleeding vaginally. It would be appropriate to monitor the fetal heart for any signs of distress, to weigh pads to determine the amount of blood loss, and to assess the hematocrit and hemoglobin to check for anemia. Labor, however, is contraindicated since vaginal delivery is contraindicated

2. The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

1. Induction is contraindicated in transverse lie. TEST-TAKING TIP: A baby in the transverse lie is in a scapular presentation. The baby is incapable of being birthed vaginally. Whenever a vaginal birth is contraindicated, induction is also contraindicated

3. A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. TEST-TAKING TIP: Oxytocin stimulates the contractility of the uterine muscle. When the muscle is contracted, the blood flow to the placenta is reduced. Whenever there is evidence of fetal compromise and oxytocin is being infused, the intravenous should be stopped immediately in order to maximize placental perfusion.

56. During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her hips. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flexing the woman's hips sharply toward her shoulders, called McRoberts' maneuver, is appropriate. TEST-TAKING TIP: Flexing the woman's hips sharply toward her shoulders increases slightly the diameter of the pelvic outlet which often enables the practitioner to successfully deliver the baby. It is especially important to note that fundal pressure is contraindicated because it may actually magnify the problem by wedging the shoulders into the pelvis even more deeply. Suprapubic pressure, on the other hand, is often helpful in assisting with the delivery.

95. The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick counts.

2. Positive fetal fibronectin levels are seen in clients who deliver preterm. TEST-TAKING TIP: Fetal fibronectin (fFN) is a substance that is metabolized by the chorion. Although positive during the first half of pregnancy, it is very rare to see positive results between 24 and 34 weeks' gestation unless the client's cervix begins to efface and dilate. It is an excellent predictor of preterm labor (PTL); therefore, many practitioners assess the cervical and vaginal secretions of women at high risk for PTL for the presence of fFN.

67. The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. The side rails of eclamptic clients' beds should be padded. TEST-TAKING TIP: Eclamptic clients have had at least one seizure. To protect them from injury during any potential subsequent seizures, the nurse should pad the head board and the side rails of the client's bed.

97. Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order. TEST-TAKING TIP: The test taker should remember that beta agonists stimulate the "fight or flight" response. The client's heart rate will increase precipitously and there is a possibility that the potassium levels of the client may fall. These side effects place the client with heart disease at risk of heart failure and/or dysrhythmias. The client is also at high risk for pulmonary edema and congestive heart failure so lung field assessments should be done regularly.

14. There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3P0020, in active labor. 2. Age 22, G1P0000, eclampsia. 3. Age 25, G4P3003, last delivery by cesarean section. 4. Age 32, G2P0100, first baby died during labor.

3. A woman, no matter what age, who has had a previous cesarean section is at risk for uterine rupture. TEST-TAKING TIP: When babies are birthed via cesarean section, the surgeon must create an incision through the uterine body. The muscles of the uterus have, therefore, been ligated and a scar has formed at the incision site. Scars are not elastic and do not contract and relax the way muscle tissue does. A vaginal birth after cesarean (VBAC) section can only be performed if the woman had a low flap (Pfannenstiel) incision in the uterus during her previous cesarean section.

46. A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G3P0020, 17 years of age. 2. G4P2101, cancer survivor. 3. G5P1211, cocaine abuser. 4. G6P0323, 27 weeks' gestation

3. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruption. TEST-TAKING TIP: It is very important that the test taker not read into any question or response. In the preceding question, all four of the women have had complicated pregnancies. The test taker should not presume the cause of the complications when they are not stated but rather look for the answer that does absolutely place the client at high risk for the abruption.

61. Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Low platelets are consistent with the diagnosis of HELLP syndrome. TEST-TAKING TIP: HELLP is the acronym for a serious complication of pregnancy and labor and delivery. The letters represent the following information: H, hemolysis; EL, elevated liver enzymes; LP, low platelets. When a client has HELLP syndrome, the nurse would, therefore, expect to see low hemoglobin and hematocrit levels, high aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, and low platelets, as seen in the scenario.

96. A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time. TEST-TAKING TIP: The client in the scenario is exhibiting signs that meet the criteria for preterm labor. The test taker should deduce, therefore, that a tocolytic agent may be ordered in this situation. The only tocolytic agent included in the choices is magnesium sulfate.

49. A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. The most common difference between placenta previa and placenta abruption is the absence or presence of abdominal pain. TEST-TAKING TIP: Because at least some of the blood from a placental abruption is trapped behind the placenta, women with that complication usually complain of intense, unrelenting pain. But because the blood from a symptomatic placenta previa flows freely through the vagina, the bleeding from that complication is virtually pain free.

55. Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia is an obstetric emergency. TEST-TAKING TIP: Dystocia means difficult delivery. A shoulder dystocia, therefore, refers to difficulty in delivering a baby's shoulders. This is an obstetric emergency since the dystocia occurs in the middle of the delivery when the head has been delivered but the shoulders remain wedged in the pelvis. The most common complications are related to nerve palsies from traction placed on the baby's head in attempts to deliver the shoulder. In addition, the baby's life is threatened since the baby is unable to breathe and umbilical cord flow is often dramatically reduced during this phase of the delivery.

69. A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.

4. The absence of seizures is an expected outcome related to magnesium sulfate administration. TEST-TAKING TIP: Eclamptic clients have seized. Magnesium sulfate is ordered and administered to these clients because it is an anticonvulsant. An expected outcome of its administration, therefore, is that the client will have no more seizures.

28. A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency. TEST-TAKING TIP: Identifying the priority action is the most difficult thing that nurses must do. The nurse must determine which of the situations is most life threatening. Of the four choices above, prolapsed cord is life threatening to the fetus. None of the other situations, as stated in the question, is life threatening to either the mother or the fetus.