Maternal Nursing: Chapter 21 (PrepU, End of Chapter Questions, NCLEX-Style Review Questions)

The nurse is caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider? A. 45 mL urine output in 2 hours. B. Hematocrit of 36% (0.36). C. Hemoglobin of 13 g/dl (130 g/L). D. Platelet count of 150,000 mm3.

A. 45 mL urine output in 2 hours. Rationale: The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record? A. Precipitous labor. B. Prolonged labor. C. Prodromal labor. D. False labor.

A. Precipitous labor. Rationale: A labor that is less than 3 hours in duration is a precipitous labor. Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20 hours or more in a first-time mother.

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? A. Use McRoberts maneuver. B. Use Zavanelli maneuver. C. Apply pressure to the fundus. D. Attempt to push in one of the fetus's shoulders.

A. Use McRoberts maneuver. Rationale: 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.

At 31 weeks' gestation, a 37-year-old client with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? A. Bed rest and hydration at home. B. Hospitalization, tocolytic, and corticosteroids. C. An emergency cesarean birth. D. Careful monitoring of fetal movement (kick) counts.

B. Hospitalization, tocolytic, and corticosteroids. Rationale: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother 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 woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: A. Increased risk for cord entanglement. B. Potential lacerations and bleeding. C. Increased risk for uterine rupture. D. Damage to the maternal tissues.

B. Potential lacerations and bleeding. Rationale: 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.

Which statement describes why hypertonic contractions tend to become very painful? A. More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other. B. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. C. The number of uterine contractions is very low or infrequent. D. There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation (dilatation).

B. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Rationale: Hypertonic contractions cause uterine cell anoxia, which is painful.

The nurse provides education to a post term pregnant client. What information will the nurse include to assist in early identification of potential problems? A. "Increase your fluid intake to prevent dehydration." B. "Be sure to measure 24-hour urine output daily." C. "Continue to monitor fetal movements daily." D. "Monitor your bowel movements for constipation."

C. "Continue to monitor fetal movements daily." Rationale: The nurse will teach the postterm client to monitor fetal movements daily to help determine if the fetus is experiencing distress.

Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? A. Stop breastfeeding and apply lanolin. B. Administer analgesics and bind both breasts. C. Apply warm or cold compresses and administer analgesics. D. Remove the nursing bra and expose the breast to fresh air.

C. Apply warm or cold compresses and administer analgesics. Rationale: Applying compresses and giving analgesics would be helpful in providing comfort to the woman with painful breasts.

A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? A. Applying a heating pad to the back. B. Applying ice to the back. C. Applying counterpressure to the back. D. Performing acupuncture on the back.

C. Applying counterpressure to the back. Rationale: Counterpressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth? A. Shoulder dystocia. B. Macrosomia. C. Cord compression. D. Fetal hydrocephalus.

C. Cord compression. Rationale: Oligohydramnios and meconium staining of the amniotic fluid are common complications of post-term pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

While assessing a postpartum multip. woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be priority? A. Assessing vital signs immediately. B. Measuring her next urinary output. C. Massaging her fundus. D. Notify woman's OB/GYN.

C. Massaging her fundus. Rationale: A boggy uterus that is midline and above the umbilicus suggests that the uterus is not contracting properly.

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? A. Placenta previa. B. Hypertonic uterus. C. Uterine rupture. D. Umbilical cord compression.

C. Uterine rupture. Rationale: 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.

Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication? A. Moderate lochia rubra for the first 24 hrs. B. Clear lung sounds upon auscultation. C. Temperature of 100F. D. Chest pain experienced when ambulating.

D. Chest pain experienced while ambulating. Rationale: May suggest a pulmonary embolism and the health care provider needs to be notified immediately.

When implementing the plan of care for a multip. postpartum woman who gave birth just a few hours ago, the nurse monitors the client for which complication? A. DVT. B. Postpartum psychosis. C. Uterine infection. D. Postpartum hemorrhage.

D. Postpartum hemorrhage. Rationale: Hemorrhage is possible if the uterus cannot contract and clamp down on the vessels to reduce bleeding.

The rationale for using a prostaglandin gel for a client prior to induction of labor is to: A. Stimulate uterine contractions. B. Numb cervical pain receptors. C. Prevent cervical lacerations. D. Soften and efface cervix.

D. Soften and efface cervix. Rationale: Prostaglandins soften and thin out the cervix in preparation for labor induction. Although they do irritate the uterus, they aren't as effective as oxytocin in stimulating contractions. Prostaglandin gel would stimulate cervical nerve receptors rather than numb them. Prostaglandins have no power to prevent cervical lacerations.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? A. The 38-year-old client whose spouse is a triplet. B. The 19-year-old client diagnosed with polycystic ovary syndrome. C. The 27-year-old client who gave birth to twins 2 years ago. D. The 41-year-old client who conceived by in vitro fertilization.

D. The 41-year-old client who conceived by in vitro fertilization. Rationale: The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

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? A. Administering oxytocin. B. Encouraging the woman to assume a hands-and-knees position. C. Providing a comfortable environment with dim lighting. D. Preparing the woman for an amniotomy.

A. Administering oxytocin. Rationale: 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.

During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. A. Assist with maneuvers. B. Keep time. C. Document events in the record. D. Lower the head of the bed. E. Administer oxytocin to increase the contractions.

A. Assist with maneuvers. B. Keep time. C. Document events in the record. D. Lower the head of the bed. Rationale: 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.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time? A. Avoid any discussion of the situation with the couple. B. Allow the couple to spend as much time as they want with their stillborn infant. C. Give the parents a lock of the infant's hair. D. Assist the family in making arrangements for their stillborn infant.

A. Avoid any discussion of the situation with the couple. Rationale: The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next? A. Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis. B. Move the client into a hands-and-knees position, to straighten the sacral curve and release the posterior shoulder. C. Apply downward pressure above the pubic bone of the client, in an attempt to rotate the anterior shoulder. D. Push the fetal head back into the uterus and prepare the client for cesarean birth

A. Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis. Rationale: To implement McRoberts maneuver, the nurse brings the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis. This maneuver enlarges the space for delivery of the fetal shoulders. Applying pressure above the pubic bone is suprapubic pressure. Pushing the fetal head back into the vagina is a Zavanelli maneuver. Since the fetal head has been delivered, it is not safe to move the client to a hands-and-knees position.

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? A. Cesarean birth. B. Administration of oxytocin. C. Administration of morphine sulfate. D. Darkening room lights and decreasing noise and stimulation.

A. Cesarean birth. Rationale: 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 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? A. Complications of a post-term pregnancy. B. Complications of preterm labor. C. Complications of placenta previa. D. Placental abruption (abruptio placentae).

A. Complications of a post-term pregnancy. Rationale: A postterm 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.

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? A. Diabetes. B. Nullipara. C. Pendulous abdomen. D. Preterm birth.

A. Diabetes. Rationale: Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

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? A. External cephalic version. B. Trial labor. C. Forceps birth. D. Vacuum extraction.

A. External cephalic version. Rationale: 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 client has arrived to the birthing center in labor, requesting a VBAC. After reading the client's previous history, the nurse anticipates that the client would be a good candidate based on which finding? A. Had previous lower abdominal incision. B. Had prior transfundal uterine surgery. C. Had prior classic uterine incision. D. Has a contracted pelvis

A. Had previous lower abdominal incision. Rationale: The choice of a vaginal or repeat cesarean birth can be offered to women who had a lower abdominal incision. Contraindications to BVAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff of facility if an emergency cesarean birth is required.

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? A. Hypotonic contractions. B. Hypertonic contractions. C. Uncoordinated contractions. D. Braxton Hicks contractions.

A. Hypotonic contractions. Rationale: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

After a vaginal exam, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: A. Intense back pain. B. Frequent leg cramps. C. Nausea and vomiting. D. Precipitous birth.

A. Intense back pain. Rationale: Having a fetus in a posterior position would cause intense back pain secondary to the fetal head facing the maternal vertebra and causing pressure. Leg cramps are common during pregnancy and not caused by an occiput posterior position, but rather pressure from the heavy gravid uterus toward term. Fetal position would not contribute to nausea and vomiting. Going through transition in labor might cause nausea and vomiting, not the fetal position. A precipitous birth occurs rapidly and is not associated with intense 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? A. Late decelerations. B. Early decelerations. C. Variable decelerations. D. Mild decelerations.

A. Late decelerations. Rationale: 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 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? A. Oxytocin, a posterior pituitary hormone. B. Antidiuretic hormone, a posterior pituitary hormone. C. Luteinizing hormone, an anterior pituitary hormone. D. Growth hormone, an anterior pituitary hormone.

A. Oxytocin, a posterior pituitary hormone. Rationale: 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.

The nurse is examining a client at 37 weeks' gestation who came to labor and delivery with severe cramps and vaginal spotting. While listening to the fetal heart rate the nurse observes a reddened area of the side of the client's abdomen. When the nurse asks about the area, the client says "I got hit with a broom." The nurse asks who hit her, but the client does not respond. A vaginal examination reveals the cervix is 50% effaced and dilated 1 cm, membranes are intact, no bleeding and the presenting part is floating. Based on the nurse's assessment, the client is admitted to the observation unit to be monitored for which obstetrical condition? A. Placental abruption (abruptio placentae). B. Preeclampsia. C. Premature labor. D. Placenta previa.

A. Placental abruption (abruptio placentae). Rationale: Trauma to the abdomen increases the risk for placenta abruption (abruptio placentae). The client's presentation with severe cramps is consistent with a potential for placental abruption. A client would be monitored for preeclampsia if she presented with elevated blood pressure, proteinuria, headache, and edema of the fingers or face. The client is at 37 weeks' gestation so she is not in premature labor. A placenta previa would present with painless vaginal bleeding.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? A. Prepare the client for a cesarean birth. B. Place the client in lithotomy position for birth. C. Administer oxytocin intravenously at 4 mU/minute. D. Perform artificial rupture of membranes.

A. Prepare the client for a cesarean birth. Rationale: Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal 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? A. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. B. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. C. Place the client in Trendelenburg position and gently attempt to reinsert the cord. D. Contact the health care provider and prepare the client for an emergent vaginal birth.

A. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Rationale: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency.

Which of the following assessment findings would lead the nurse to suspect an amniotic fluid embolism? A. Respiratory distress. B. Hypertension. C. Acute abdominal pain. D. Sudden fetal distress.

A. Respiratory distress. Rationale: Amniotic fluid embolism should be suspected in any pregnant woman with an acute onset of respiratory distress and hypotension. Sudden fetal distress and acute abdominal pain are associated with uterine rupture.

The nurse would prepare a client for amnioinfusion when which action occurs? A. Severe variable decelerations occur and are due to cord compression. B. Fetal presenting part fails to rotate fully and descend in the pelvis. C. The fetus shows abnormal fetal heart rate patterns. D. Maternal pushing is compromised due to anesthesia.

A. Severe variable decelerations occur and are due to cord compression. Rationale: Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amnioinfusion.

Is the following statement True or False? Psychological stress in the woman can contribute to dystocia. A. True. B. False.

A. True. Rationale: Emotions such as fear, anxiety, helplessness, being alone, and weariness can lead to psychological stress, indirectly causing dystocia.

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: A. 3,500 g to 4000 g. B. 4,000 g to 4500 g. C. 2500 to 3000 g. D. 3,000 g to 3500 g.

B. 4,000 g to 4500 g. Rationale: Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: A. 7. B. 5. C. 9. D. 6.

B. 5. Rationale: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply. A. Arterial blood gases. B. Amniotic fluid analysis. C. U/A. D. Thyroid level. E. Complete blood count.

B. Amniotic fluid analysis. C. U/A. E. Complete blood count. Rationale: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.

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? A. Place the woman in Trendelenburg position. B. Assess fetal heart sounds. C. Administer amnioinfusion. D. Administer oxygen at 10 L/min by face mask.

B. Assess fetal heart sounds. Rationale: 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.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? A. Perineal hematoma. B. Caput succedaneum. C. Infection of episiotomy. D. Cervical lacerations.

B. Caput succedaneum. Rationale: 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.

A client arrives in the labor and delivery unit in the beginning early phase with the contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the client in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the client for which priority assessment caused by a rapid birth? A. Assess bladder for fullness. B. Check perineal area frequently for bleeding. C. Assess the woman's breathing and intervene if necessary. D. Assess and administer pain medication as needed.

B. Check perineal area frequently for bleeding. Rationale: Precipitous dilation (dilatation) is cervical dilation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara. Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the perineum, placing the woman at risk for hemorrhage. The other interventions are appropriate, but the priority is assessing for bleeding/hemorrhage.

Which clients should the nurse monitor for fetal demise? Select all that apply. A. Client with hydramnios. B. Client with hypertension. C. Client with multifetal gestation. D. Client who has a prolonged pregnancy. E. Client whose fetus is displaying malpresentation.

B. Client with hypertension. D. Client who has a prolonged pregnancy.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? A. Applying suprapubic pressure against the fetal back. B. Continuing to monitor maternal and fetal status. C. Noting the space at the maternal umbilicus. D. Auscultating the fetal heart rate at the level of the umbilicus.

B. Continuing to monitor maternal and fetal status. Rationale: 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 occiput posterior positioning of the fetus.

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? A. Elevated blood glucose. B. Depressed deep tendon reflexes. C. Bradycardia. D. Tachypnea.

B. Depressed deep tendon reflexes. Rationale: The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline.

The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? A. Need to have the baby manually rotated. B. Experience of additional back pain. C. Shorter dilation (dilatation) stage of labor. D. Necessity for vacuum extraction for birth.

B. Experience of additional back pain. Rationale: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

Is the following statement True or False? Oxytocin is an important agent used to ripen the cervix for labor induction. A. True. B. False.

B. False. Rationale Oxytocin is used to induce or augment labor once the cervix is ripe

Is the following statement True or False? An amnioinfusion is appropriate for a pregnant woman experiencing a prolonged second stage of labor. A. True. B. False.

B. False. Rationale: Amnioinfusion is indicated for severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid. A forceps- or vacuum-assisted birth would be indicated for a prolonged second stage of labor.

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which information would the nurse expect to find? A. Preterm pregnancy. B. Gestational diabetes. C. Maternal rickets. D. Small body size of mother.

B. Gestational diabetes. Rationale: Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or postterm pregnancy. Preterm pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet.

The nurse would anticipate a C-section for a client who has which active infection present at the onset of labor? A. Hepatitis. B. Herpes simplex virus. C. Toxoplasmosis. D. Human pap.

B. Herpes simplex virus. Rationale: Herpes exposure during the birth process poses a high risk for mortality to the neonate. If the woman has active herpetic lesions in the genital tract, a surgical birth is planned to avoid this exposure. Hepatitis is a chronic liver disorder, and the fetus if exposed would at most become a carrier; a surgical birth would not be expected for this woman. Toxoplasmosis is passed through the placenta to the fetus prior to birth, so a cesarean birth would not prevent exposure. HPV would be manifested clinically by genital warts on the woman, and a surgical birth would not be anticipated to prevent exposure unless the warts caused an obstruction.

A nurse is caring for a client who has been diagnosed with precipitous labor. For which potential fetal complication should the nurse monitor? A. Cephalohematoma. B. Intracranial hemorrhage. C. Facial nerve injury. D. Facial lacerations.

B. Intracranial hemorrhage. Rationale: The nurse should assess for fetal complications such as head trauma associated with intracranial hemorrhage, nerve damage, and hypoxia in cases of precipitous labor. Facial and scalp lacerations, facial nerve injury, and cephalohematoma are all newborn traumas associated with the use of the forceps of vacuum extractors during birth. These conditions are not neonatal complications associated with precipitous labor.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition? A. Hemorrhage. B. Macrosomia. C. Infection. D. Dystocia.

B. Macrosomia. Rational: Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia are risk to the mother not the fetus.

A nursing student correctly identifies the most desirable position to promote an easy birth as which position? A. Breech. B. Occiput anterior. C. Face and brow. D. Shoulder dystocia.

B. Occiput anterior. Rationale: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

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? A. Explain to her that there was probably something wrong with the infant and that is why it died. B. Offer to take pictures and footprints of the infant once it is delivered. C. Call the hospital chaplain to talk to the parents. D. Recommend that she not hold the infant after it is delivered so as to not upset her more.

B. Offer to take pictures and footprints of the infant once it is delivered. Rationale: 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 fetus of a client in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize? A. Side-lying position. B. Pain relief measures. C. Immediate cesarean birth. D. Oxytocin administration.

B. Pain relief measures. Rationale: Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: A. Encourage ambulation every 30 min. B. Provide pain relief measures. C. Monitor the Pitocin infusion rate closely. D. Prepare the woman for an amniotomy.

B. Provide pain relief measures. Rationale: As women with hypertonic uterine contractions experience a high level of pain related to the high intensity of contractions. Providing comfort measures along with pharmacologic agents to reduce would be a priority. Response "A" is incorrect since a woman experiencing a high level of pain secondary to contraction intensity would not feel like ambulating during this challenging time period. Response "C" is incorrect because with this type of dystocia, augmentation of labor contractions would not be needed. If Pitocin had been infusing prior to the identification of this dystocia pattern, it would be discontinued to reduce the intensity of the contractions.

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? A. Low potassium or elevated glucose, tachycardia, chest pain. B. Respiratory depression, hypotension, absent tendon reflexes. C. Severe lower back pain, leg cramps, sweating. D. Pain in the abdomen, shoulder, or back.

B. Respiratory depression, hypotension, absent tendon reflexes. Rationale: 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.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? A. Bradypnea. B. Sudden shortness of breath. C. Bradycardia. D. Unrelieved pain.

B. Sudden shortness of breath. Rationale: 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.

The nursing student demonstrates an understanding of dystocia with which statement? A. "Dystocia is not diagnosed until after the delivery." B. "Dystocia is diagnosed at the start of labor." C. "Dystocia is diagnosed after labor has progressed for a time." D. "Dystocia cannot be diagnosed until just before delivery."

C. "Dystocia is diagnosed after labor has progressed for a time." Rationale: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the patient and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? A. 2 cm/hour for cervical dilation. B. 1/2 cm/hour for cervical dilation. C. 1 cm/hour for cervical dilation. D. 1/4 cm/hour for cervical dilation.

C. 1 cm/hour for cervical dilation. Rationale: In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

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 with the birth? A. To lessen the mother's pain. B. The fetus is descending too slowly. C. Abnormal position of the fetal head. D. Reduce risk of complications

C. Abnormal position of the fetal head. Rationale: Forceps are mechanical devices which can be used to help deliver the fetus. Although no longer used routinely they are still used in certain situations to assist with the birth. One of those situations is when the fetus is in an abnormal position and the health care provider attempts to reposition the fetus to facilitate birth. The use of forceps is not to lessen the mother's pain or to speed up the process. The use of forceps is not without risk of complications, include perineal lacerations and injury to the fetus if the forceps are not used correctly.

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? A. Placental separation. B. Aspiration. C. Amniotic fluid embolism. D. Congestive heart failure.

C. Amniotic fluid embolism. Rationale: 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.

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: A. Call the client's health care provider immediately. B. Immediately set up an IV of Mg sulfate. C. Assess the fundus and ask about her voiding status. D. Reassure the mother that this is a normal finding after childbirth.

C. Assess the fundus and ask about her voiding status. Rationale: It is important to assess the situation before intervening. In addition, checking the bladder status and emptying a full bladder will correct uterine displacement so that effective contractions to stop bleeding can occur.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates: A. No infection is present. B. Birth is likely within the next 2 weeks. C. Birth is unlikely within the 2 next weeks. D. Infection is present.

C. Birth is unlikely within the 2 next weeks. Rationale: Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that delivery is unlikely within 2 weeks following the test. It does not diagnose infection.

Before calling the health care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the health care provider? A. Make sure the epidural medication is turned down. B. Assess vital signs every 30 minutes. C. Check for a full bladder. D. Make sure the client is lying on her left side.

C. Check for a full bladder. Rationale: A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: A. Hypertonic labor. B. Precipitate labor. C. Hypotonic labor. D. Dysfunctional labor.

C. Hypotonic labor. Rationale: Hypotonic labor typically occurs in the active phase; it involves ineffective contractions to evoke cervical dilation and causes secondary inertia. Hypertonic labor is characterized by painful, high-intensity contractions that usually occur in the latent phase. Precipitous labor occurs within 3 hours and cervical dilation is very fast secondary to effective, high-intensity contractions. Dysfunctional labor describes any pattern that doesn't produce dilation and effacement in a timely manner.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: A. Longer length of labor. B. Increased number of overall pregnancies. C. Increasing birth weight. D. Poor quality of prenatal care.

C. Increasing birth weight. Rationale: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? A. Contacting a grief counselor. B. Removing the infant quickly. C. Keeping the communication lines open. D. Leaving the parents alone.

C. Keeping the communication lines open. Rationale: Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye.

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? A. Monitor heart rate for tachycardia. B. Monitor fetal movements to ensure they are neurologically intact. C. Look for late decelerations on monitor, which is associated with fetal anoxia. D. Monitor fetal blood pressure for signs of shock (low BP, high FHR).

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

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? A. McDonald maneuver. B. McGeorge maneuver. C. McRoberts maneuver. D. McRonald maneuver.

C. McRoberts maneuver. Rationale: 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 developing a plan of care for a woman experiencing dystocia. Which of the following nursing interventions would be the nurse's high priority? A. Changing woman's position frequently. B. Providing comfort measures to the woman. C. Monitoring the fetal heart rate patterns. D. Keeping the couple informed of the labor progress.

C. Monitoring the fetal heart rate patterns. Rationale: The correct response is "C" because the health status of the fetus is paramount throughout the labor process to identify any deviations in a timely manner for decisive interventions to be initiated. Responses "A," "B," and "D" are all important nursing interventions, but don't become the priority over the fetal health status during the labor.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? A. Breech presentation. B. Occiput posterior position. C. Fetal macrosomia. D. Non Gynecoid pelvis.

C. Occiput posterior position. Rationale: A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

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? A. Administer an analgesic to the client. B. Prepare the client for a cesarean birth. C. Prepare for a precipitous vaginal birth. D. Prepare to assist the care provider with an amniotomy.

C. Prepare the client for a cesarean birth. Rationale: 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.

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? A. Encouraging the women to change positions frequently. B. Preparing the woman for an amniotomy. C. Providing a comfortable environment with dim lighting. D. Administering oxytocin.

C. Providing a comfortable environment with dim lighting. Rationale: 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).

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? A. Contractions most forceful in the middle of uterus rather than the fundus. B. Fetal buttocks as the presenting part. C. Reports of severe back pain. D. Lack of cervical dilation (dilatation) past 2 cm.

C. Reports of severe back pain. Rationale: Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation (dilatation) that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mmHg. Which action would be most appropriate? A. Slow the oxytocin infusion to the initial rate. B. Continue to monitor contractions and fetal heart rate. C. Stop the infusion immediately. D. Notify the birth attendant.

C. Stop the infusion immediately. Rationale: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

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? A. The parents continue to mourn the loss of their infant. B. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn. C. The parents are beginning to demonstrate positive grieving behaviors. D. The parents just cannot believe their perfect infant died.

C. The parents are beginning to demonstrate positive grieving behaviors. Rationale: 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 woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect? A. Fractured ribs. B. Placenta previa. C. Uterine rupture. D. Dystocia.

C. Uterine rupture. Rationale: A uterine rupture should be suspected in a pregnant woman who has experienced blunt trauma to the abdomen and then complains of severe pain in her back and shoulder. Uterine rupture occurs when the uterus tears open, leaving the fetus and other uterine contents exposed to the peritoneal cavity. Traumatic rupture can occur in connection with a blunt trauma. Abrupt change in the fetal heart rate pattern is often the most significant sign associated with uterine rupture. Other signs are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. The scenario presented does not indicate fractured ribs from the accident. Placental abruption (abruptio placentae) presents with pain; dark red vaginal bleeding; a rigid, board-like abdomen; hypertonic labor; and fetal distress. Pain has a sudden onset and is constant, and the uterus may not relax well between contractions. Dystocia is the abnormally slow progression of labor, which is not indicated.

A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor? A. Fetal heart rate (FHR) increase to 200 beats/min. B. Late deceleration with late recovery following contraction. C. Variable deceleration pattern. D. Early deceleration with each contraction.

C. Variable deceleration pattern. Rationale: Umbilical cord prolapse can be seen after the membranes have ruptured, when the FHR is displaying a sudden variable deceleration FHR pattern on a fetal monitor. It is not uncommon for FHR to increase following a procedure. Early deceleration with each contraction is seen when the fetal head is being compressed through the pelvic opening. Late deceleration with late recovery following contraction is associated with uteroplacental insufficiency (UPI).

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? A. "Maybe your uterus is just tired and needs a rest." B. "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." C. "Maybe your baby has developed hydrocephaly and the head is too swollen." D. "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

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

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? A. Prostaglandin. B. Laminaria. C. Breast stimulation. D. Amniotomy.

D. Amniotomy. Rationale: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment post birth? A. Assess for cleft palate. B. Monitor for a cardiac anomaly. C. Extensive lacerations. D. Brachial plexus assessment.

D. Brachial plexus assessment. Rationale: The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor? A. Woman who had twins in a previous pregnancy. B. Client living in a large city close to subway. C. Woman working full-time as computer programmer. D. Client with history of previous preterm birth.

D. Client with a history of previous preterm birth. Rationale: Women with a history of preterm birth are at the highest risk for the same in subsequent pregnancies. Having had twins previously would have no bearing on this singleton pregnancy to influence preterm labor. Location of residence is not a risk for preterm labor. The woman's occupation as a computer programmer would not increase her risk of preterm labor. However, standing for long periods in a work environment might increase her risk.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction? A. Lack of cervical dilation past 2 cm. B. Fetal buttocks as the presenting part. C. Reports of severe back pain. D. Contractions most forceful in the middle of uterus rather than the fundus.

D. Contractions most forceful in the middle of uterus rather than the fundus. Rationale: Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation (dilatation) that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

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? A. Arrest of the descent of the fetal head. B. Prolonged deceleration phase. C. Secondary arrest of cervical dilation (dilatation). D. Delayed descent of the fetal head.

D. Delayed descent of the fetal head. Rationale: Protraction disorders are characterized by delayed descent of the fetal head and delayed cervical dilation (dilatation). Prolonged deceleration phase, secondary arrest of cervical dilation, and arrest of the descent of the fetal head are characteristics of arrest disorder and not of protraction disorder.

The nurse is monitoring a woman who is receiving IV oxytocin 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? A. Continue to monitor contraction duration every 2 hours. B. Increase the flow rate of the main line infusion. C. Slow the infusion to under 10 gtts per minute. D. Discontinue the oxytocin infusion.

D. Discontinue the oxytocin infusion. Rationale: If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allow fetal nourishment. The nurse would not increase the flow rate of the main line infusion or slow the infusion without the health care provider's prescription. Uterine contractions are monitored continuously.

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: A. Cervical insufficiency. B. Contracted pelvis. C. Maternal disproportion. D. Fetopelvic disproportion.

D. Fetopelvic disproportion. Rationale: Fetopelvic disproportion occurs when fetus is too large to pass through the maternal pelvis. Cervical insufficiency would lead to an abortion, typically in the second trimester, when the heavy gravid uterus would cause pressure on the weakened cervix. Contracted pelvis might cause passageway problems, but if the fetus was small, no problem might occur. Maternal disproportion doesn't indicate where the disproportion is located.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum? A. Fraternal. B. Neither type results from a split ovum. C, Both types can result from the split ovum. D. Identical.

D. Identical. Rationale: The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? A. Betamethasone. B. Nifedipine. C. Indomethacin. D. Magnesium sulfate.

D. Magnesium sulfate. Rationale: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Terbutaline is given intravenously during the initial period and then switched to the oral route for maintenance.

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? A. Morphine sulfate. B. Betamethasone. C. Terbutaline. D. Oxytocin.

D. Oxytocin. Rationale: Oxytocin administration may be helpful in uncoordinated labor to stimulate a more effective and consistent pattern of contractions with a better, lower resting tone.

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? A. Genetic abnormality. B. Preeclampsia. C. Premature rupture of membranes. D. Placental abruption.

D. Placental abruption. Rationale: 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.

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 the abdomen and shoulder. What should the nurse prepare to do? A. Turn the client on her left side. B. Place the client in a knee-chest position. C. Bolus the client with another dose of medication through the epidural. D. Prepare the client for a cesarean birth.

D. Prepare the client for a cesarean birth. Rationale: The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous effective pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

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? A. Assist with nitrazine and fern tests. B. Include a set of piper forceps when the table is prepped. C. Apply pressure to the woman's lower back with a fisted hand. D. Prepare to assist with external version.

D. Prepare to assist with external version. Rationale: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via a 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. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning.

A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? A. Console her with the fact that she has other children. B. Tell her that the hospital will keep the photos for her in case she changes her mind. C. Apologize and tell her that the photos will be destroyed immediately. D. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.

D. Tell her that the hospital will keep the photos for her in case she changes her mind. Rationale: Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the birth. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

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? A. The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. B. The uterine contractions are irregular, but the quantity or quality or strength is insufficient to dilate the cervix. C. The uterine contractions are regular, but the quantity or quality or strength is insufficient to dilate the cervix. D. The uterine contractions may or may not be regular, but the quantity or quality or strength is sufficient to dilate the cervix.

D. The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. Rationale: There are two types of uterine dysfunction: hypotonic and hypertonic. The most common is hypotonic dysfunction. This labor pattern manifests by uterine contractions that may or may not be regular, but the quantity or strength is insufficient to dilate the cervix.

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? A. Today at 2200. B. Tomorrow at 0800. C. Tomorrow at 1200. D. Tomorrow at 1400. E. Tomorrow at 1800.

D. Tomorrow at 1400. Rationale: 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 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? A. Compression on the inferior vena cava. B. An amniotic embolism to the lungs. C. An undiagnosed abdominal aorta aneurysm D. Uterine rupture.

D. Uterine rupture. Rationale: 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. Urgent delivery by cesarean birth is usually indicated

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. A. "Maybe dimming the lights or some soft music will help you relax a bit." B. "Let me leave you alone for a little while so you can get some rest." C. "I will keep you updated often on how you and your baby are doing." D. "Things are moving along but sometimes it can take a little longer." E. "I will have to stop giving you pain medicine because it is slowing your labor."

A. "Maybe dimming the lights or some soft music will help you relax a bit." C. "I will keep you updated often on how you and your baby are doing." D. "Things are moving along but sometimes it can take a little longer." Rationale: 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.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention? A. A forceps and vacuum-assisted birth. B. A precipitous birth. C. Artificial rupture of membranes. D. A cesarean birth.

A. A forceps and vacuum-assisted birth. Rationale: A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: A. Administer oxygen by mask. B. Increase her intravenous fluid infusion rate. C. Put firm pressure on the fundus of her uterus. D. Tell the woman to take short, catchy breaths.

A. Administer oxygen by mask. Rationale: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin diluted as a "piggyback" infusion. B. Administer oxytocin in a 20 cc bolus of saline. C. Administer oxytocin diluted in the main intravenous fluid. D. Administer oxytocin in two divided intramuscular sites.

A. Administer oxytocin diluted as a "piggyback" infusion. Rationale: Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.