Maternity: Complications before & during labor and delivery
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status.
A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?
A previous myomectomy to remove fibroids can be associated with the cause of placenta previa. Risk factors also include maternal age greater than 30 years.
Which assessment finding will alert the nurse to be on the lookout for possible placental abruption during labor?
Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, intimate partner violence, and placental pathology.
A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement?
"Ill drink several glasses of water." If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction.
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question?
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." Arrest of descent 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.
During active labor, the nurse notes a decrease in the baby's fetal heart rate and consults with the health care provider. The provider concurs and prescribes application of oxygen via mask, increase in IV fluids, and repositioning. The nurse should communicate which piece of information to the woman when she protests about being "tied down" in bed with IVs?
"Remember the goal is to increase the FHR so a healthy infant can be born." If a woman develops a complication of labor or birth, actions to increase the fetal heart rate (FHR) or to strengthen uterine contractions are a priority and possibly an emergency. Interventions must be planned and performed efficiently and effectively, based on the individual circumstances. Focusing on IV lines, rationale for oxygen placement, or educating about changing position does not put the focus on the priority—a healthy baby.
The mother comes to her prenatal appointment. She tells the nurse that it feels like the baby is kicking on her bladder and it is harder to breathe. The nurse suspects the fetus is in breech position. Which procedure would the nurse implement to determine the position of the baby?
Leopold maneuvers Diagnosis of breech presentation is usually by Leopold maneuvers. These maneuvers are done by palpating the maternal abdomen to feel the location of the fetal parts (head, back, buttocks, etc.). A sign of breech presentation is the mother's report of pressure from the fetal head against the fundus and kicking in the lower abdomen.
The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?
45 ml urine output in 2 hours
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
4th degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth?
8 or higher The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11 would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect?
A major adverse effect of the obstetric use of misoprostol is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism.
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 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.
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction?
A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.
A multipara woman is experiencing a prolonged descent while trying to rest and increase her fluid intake. The nurse suggests that she change position. Which position(s) will be effective for pushing to speed up the descent?
A semi-Fowler position or a squatting, kneeling position will be most effective for pushing and may speed descent.
The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery?
Abnormal position of the fetal head 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 deliver. 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 to include perineal lacerations and injury to the fetus if done incorrectly.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
Administer O2 An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
Amniotic fluid embolism; symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
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?
Amniotomy 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.
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?
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 pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient?
Assess fetal heart sounds with external monitor. For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine contractions are contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both mother and child. To ensure an adequate blood supply to the patient and fetus, the patient should be placed immediately on bed rest in a side-lying position.
During a prenatal ultrasound, the client is discovered to have a placenta succenturiata. Following delivery of the fetus and placenta, which nursing assessment is most important?
Assessment for hemorrhage. Placenta succenturiata can be first identified with a sonogram as the placenta is composed of several lobes instead of being one structure. A danger of this type of placental formation is that a lobe may tear and remain in the uterus after delivery. Assessment for hemorrhage is most important following delivery and in the postpartum period.
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?
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.
The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions?
Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min Hyperstimulation is usually defined as five or more contractions in a 10-minute period or contractions lasting more than 2 minutes in duration or occurring within 60 seconds of each other. The surest method to relieve hyperstimulation is to immediately discontinue the oxytocin infusion. The rate should not be increased by more than 2 milliunits at a time. When the infusion is administered, the oxytocin solution should be "piggybacked" to a maintenance IV solution such as Ringer's lactate and the piggyback added to the main infusion at the port closest to the woman. Infusions are usually begun at a rate of 1 to 2 milliunits/min. If there is no response, the infusion is gradually increased every 30 to 60 minutes by small increments of 1 to 2 milliunits/min until contractions begin.
A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation?
Catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.
Before calling the primary 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 care provider?
Check for full bladder A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.
Which finding would lead the nurse to suspect that the fetus of a woman in labor in in hypertonic uterine dysfunction?
Contractions are most forceful in the middle of the uterus than the fundus.
A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is post-term and has oligohydramnios. What does this increase the risk of during birth?
Cord compression
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?
DEEP TENDON REFLEXES 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.
A client in the active phase of labor is diagnosed as having a protracted labor pattern. Which pattern would the nurse assess as indicative of a protracted labor pattern?
Delayed decent of fetal head Protraction disorders are characterized by delayed descent of the fetal head and delayed cervical dilation.
A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?
Diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies.
A pregnant patient is prescribed to have labor induced with oxytocin. How should the nurse prepare to administer this medication?
Diluted as a "piggyback" infusion When administering oxytocin, the infusion should be "piggybacked" to a maintenance IV solution and add the piggyback to the main infusion at the port closest to the patient. If the oxytocin needs to be discontinued quickly during the induction, little solution remains in the tubing to still infuse, and the main IV line can still be maintained. Oxytocin is not administered as an intravenous bolus, as intramuscular injections, nor is it diluted in the main intravenous fluid.
The nurse is monitoring a woman who is receiving oxytocin IV to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?
Discontinue oxytocin 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 primary care provider's prescription. Uterine contractions are monitored continuously.
The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?
External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.
What are indications for forceps-assisted birth?
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.
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?
Fetal heart tones When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable.
Post term pregnancies include what problems for the fetus?
Fetal risks associated with a post-term pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline after 38 weeks' gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult (Norwitz, 2019). All of these issues can compromise fetal well-being and lead to fetal distress.
The fetus of a pregnant patient is in a breech presentation. Where will the nurse auscultate fetal heart sounds?
High in abdomen With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?
Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.
What are indications of hypertonic uterine contractions?
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. Hypertonic occur frequently and are most commonly seen in the latent phase of labor
A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?
Hypotonic Uterine contractions 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. .
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?
Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. (It is not a tocolytic agent.)
A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms?
If rhythmical, they could indicate preterm labor Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. These sensations are Braxton Hicks contractions and can be similar to a forceful menstrual cramp. These contractions are not usually a sign of beginning labor but should be reported for evaluation. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor. Exercise or rest does not reduce the frequency of Braxton Hicks contractions.
The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?
In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?
Knee-Chest Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
What is a mechanical method of cervical ripening?
Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical ripening.
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?
Late decelerations 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.
A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor?
Lecithin/sphingomyelin ratio The lecithin/sphingomyelin (L/S) ratio of the amniotic fluid helps predict the fetal lung maturity in a client with PROM who goes into labor.
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?
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.
A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?
Meconium stained fluid Green-tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called mecomium-stained fluid. This is more typical in a postdate pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.
A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis?
Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. (Used for cervical ripening, not tocolysis) Dinoprostone and misoprostol are used to ripen the cervix.
The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
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.
A mother having her third baby is to deliver via a repeat cesarean section. Which factors in the mother's history that place her at a higher risk for hemorrhage and the need for blood transfusions should the nurse identify?
Multiple cesarean sections Placental accreta with first delivery A woman is considered at higher risk for transfusion during delivery under these conditions: use of general anesthesia; history of multiple cesarean sections; anemic prior to the birth; severe preeclampsia, eclampsia, or HELLP syndrome; and placental complications such as placenta previa, placental abruption, or placenta accreta.
The nurse is caring for a woman at 32 weeks' gestation who expresses deep concern because her previous pregnancy ended in a stillbirth. The nurse would encourage the mother to have what screening test?
Nonstress test Women with a history of previous stillbirth begin antepartum fetal testing 1 to 2 weeks prior to the gestational age at which the intrauterine demise occurred, or no later than 32 to 34 weeks' gestation. One method to assess the well-being of the fetus is the biophysical profile. Included in this is the nonstress test. Other regular screening methods are having the mother keep a record of kicks, and monitoring for hypertensive disorders and diabetes. An abdominal ultrasound could screen for fetal growth restriction. A Doppler ultrasound measures the blood flow of the fetus but it not part of the regular screening unless fetal problems have been identified.
What are adequate antibiotic treatments for GBS?
Only treatment with penicillin G, ampicillin or cefazolin is considered adequate for the treatment of GBS.
A patient is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient?
Oxytocin therapy
What dysfunction in the powers of labor occurs when the uterus contracts so frequently and with such intensity that a very rapid birth takes place?
Precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).
A pregnant client arrives at the clinic for a regular antenatal check-up. Examinations and weight recording reveal a slow fetal weight gain. About which of the following pregnancy-related risks should the nurse alert the client?
Preterm labor The nurse should alert the client with slowed fetal growth that she may experience a preterm labor. Preterm labor is common among women who show slowed fetal growth.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression 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 amniofusion.
The nurse is teaching a birthing class to pregnant mothers. What information does the nurse teach the mothers about having an upright position during the first stage of labor?
Shortens the 1st stage of labor improves uteroplacental perfusion reduces labor pain reduces rate of surgical vaginal deliveries. An upright position can shorten the first stage of labor by 90 minutes and the second stage of labor by 4 minutes. This position improves uteroplacental profusion, reduces labor pain, reduces surgical deliveries, and reduces the episiotomy rate. It does not, however, decrease the rate of second-degree or higher lacerations and postpartum hemorrhage. Rather, it increases these.
The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus?
Shoulder dystocia
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?
Stop Oxytocin Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.
A client has been admitted with placental abruption. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae?
The classifications for abruptio placentae are: grade 1 (mild) - minimal bleeding (less than 500 mL), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 mL), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 mL), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?
The fundus is located 2 fingerbreadths above the umbilicus The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate.
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?
The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. Trauma does not usually cause PROM.
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?
The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the cord to ensure it's 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. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.
When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area?
Through the anal sphincter muscle
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?
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.
A nurse is reviewing an article about preterm prelabor rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply.
UTI low SES Smoking
A pregnant woman at the emergency department informs staff that she is at least 2 weeks past her due date. The physician begins to perform several tests to determine fetal age. The nurse anticipates that the woman's amniotic fluid volume will be decreased. How would the nurse measure the amniotic fluid in this situation?
Ultrasound When a patient presents with an intrauterine pregnancy at or past 42 weeks, the team will attempt to determine fetal age using different methods. Decreased amniotic fluid may be present and can be measured by ultrasound. The other methods cannot determine volume of amniotic fluid.
A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?
Umbilical cord prolapse Because the patient is not in labor, this development is considered premature rupture of membranes. The sudden onset of deep variable decelerations may indicate umbilical cord prolapse, which is an obstetric emergency that requires immediate intervention
What are uncoordinated contractions?
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.
A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem?
Uterine contractions are weak and ineffective. Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.
A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?
Uterine rupture is associated with crack cocaine use disorder. Generally, the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?
Walking is the best way to prevent complications such as blood clots.
Are early decelerations a normal finding?
Yes, early decelerations are a normal finding.
A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?
brachial plexus assessment 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.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status 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.
A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?
fetopelvic disproportion The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus.
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be
place a hand gently on the fetal head to guide birth
A nursing instructor identifies which factor as increasing the chances of infection when coupled with prolonged labor?
premature rupture of membranes
