Saunders: Maternal nursing questions
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? A) Variability. B) Accelerations. C) Early deceleration. D) Variable decelerations.
Answer: D Rational: Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline FHR. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the FHR between contractions is 100 BPM. Which nursing action is most appropriate? A) Notify the primary care provider. B) Continue to monitor the FHR. C) Encourage the client to continue pushing with each contraction. D) Instruct the clients coach to continue to encourage breathing techniques.
Answer: A Rational: A normal FHR is 110 to 160 BPM, and the FHR should be within range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management and the PHCP should be notified. Options B, C, and D are inappropriate nursing actions in this situation and delay necessary interventions.
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to? A) Provide pain relief measures B) Prepare the client for an amniotomy C) Promote ambulation every 30 minutes D)Monitor the oxytocin infusion closely
Answer: A Rational: Hypertonic contractions are painful, occur frequently and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? A) Administer oxygen via face mask. B) Place the client in a supine position. C) Increase the rate of oxytocin intravenous infusion. D) Document the findings and continue to monitor the fetal patterns.
Answer: A Rational: Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results: oxygen at 8 to 10L/ minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client needs to be turned onto the side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous infusion of Oxytocin is discontinued when a late deceleration is noted. The Oxytocin would cause further hypoxemia because of increased uteroplacental insufficiencies resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option D would delay necessary treatment.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occur every 2 to 3 minutes, with a duration of 60 seconds. An internal FHR monitor is in place. The baseline FHR has been 120 to 122 BPM for the past hour. What is the priority nursing action? A) Discontinue the infusion of Pitocin. B) Notify the primary health care provider. C) Place oxygen on at 8 to 10 L/minute via face mask. D) Contact the client's primary support person if not currently present.
Answer: A Rational: The priority nursing action is to stop the infusion of Oxytocin. Oxytocin can cause forceful uterine contractions and decreases oxygenation to the placenta, resulting in decreases variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying the PHCP, apply oxygen, and increasing the rate of the intravenous fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's PHCP is not the priority nursing action at this time.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse would place the client in which position? A) Supine position with a wedge under the right hip. B) Trendelenburg's position with the legs in stirrups. C) Prone position with the legs separated and elevated. D) Semi fowlers position with a pillow under the knees.
Answer: A Rational: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position place pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-fowlers position is impractical for this type of abdominal surgery.
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines which risk factors in the client's history places the client at risk for complications? Select all that apply. A) Age 45 years B) Body mass index of 28 C) Previous difficulty with fertility D) Administration of oxytocin for induction E) Potassium level of 3.6 mEq/L
Answer: A, B, C Rational: Risk factors that increase a women's risk for dystocia include the following: Advanced maternal age, being overweight, electrolyte imbalance, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 45 years is considered advanced maternal age, and a body index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. A potassium of 3.6 mEq/L is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primacy care provider? A) Hemoglobin of 11g/dL (110 mmol/L. B) FHR of 180 BPM. C) Maternal pulse of 85 BPM. D) White blood cell count of 12,000/mm3.
Answer: B Rational: A normal FHR is 110 to 160 BPM. A FHR of 180 BPM could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to13 g/dL (110 to 130 mmol/L because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 BPM over prepregnancy readings to facilitate increased cardiac output, oxygen transport and kidney filtration. White blood cell count in a normal pregnancy begin to increase in the second trimester and peak in the third trimester with a normal range of 11,000 to 15,000/mm3 up to 18,000/mm3. During the immediate postpartum period the white blood cell count may be 25,000 to 30,000/mm3 because of increases leukocytosis that occurs during delivery
The nurse is admitting a pregnant client to the labor room and attaches an external fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? A) Identify the types of accelerations. B) Assess the baseline FHR. C) Determine the intensity of the contractions. D) Determine the frequency of the contractions.
Answer: B Rational: Assessing the baseline FHR is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options A and D are important to assess, but not as the first priority. FHR is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the FHR.
The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? A) Providing comfort measures B) Monitoring FHR C) Changing the client position frequently D) Keeping the significant other informed of the progress of labor
Answer: B Rational: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the FHR. Although providing comfort measures, changing the clients position frequently, and keeping the significant other informed of the progress of labor are components of the plan of care, the fetus statis would be the priority.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? A) The client is a 35-year-old primigravida. B) The client has a history of cardiac disease. C) The client's hemoglobin level is 13.5 g/dL (135/mmol/L) D) The client is a 20-year-old primigravida of average weight and height
Answer: B Rational: Preterm labor occurs after the 20th week of gestation and before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetrical problems, social and environmental factors, and substance abuse. Other risks include a multifetal pregnancy which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40.
The nurse has been working with a laboring client and notes that the client has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? A) Ambulation. B) Rest between contractions. C) Change positions frequently. D) Consume oral food and fluids.
Answer: B Rational: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A) Gently push the cord into the vagina B) Place the client in Trendelenburg's position C) Find the closest telephone and page the PHCP stat D) Call the delivery room to notify the staff that the client will be transported immediately
Answer: B Rational: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client would be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse would call the PHCP and notify the delivery room. If the cord is protruding from the vagina, no attempt is made to replace it because to do so could traumatize it and reduce blood flow further. Also, as a first action, the examiner would place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen 8 to 10 L/Minute by face mask is administered to the client o increase fetal oxygenation.
Which assessment finding after an amniotomy needs to be conducted first? A) Cervical dilation. B) Bladder distention. C) FHR pattern. D) Maternal BP
Answer: C Rational: FHR is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal BP would not be the first thing to check after an amniotomy.
A nurse is reviewing the PHCP prescriptions for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription would the nurse question? A) Monitor FHR continuously B) Monitor maternal vital signs frequently C) Perform vaginal examinations every shift D) Administer an antibiotic per prescription and per agency policy
Answer: C Rational: Vaginal examinations should not be done routinely in a client with premature rupture of membranes because of the risk for infection. The nurse would expect to monitor FHR, monitor maternal vitals, and administer an antibiotic.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. A) The contractions are regular. B) The membranes have ruptured. C) The cervix is dilated completely. D) The client begins to expel clear vaginal fluid. E) The Feguson reflex is initiated from perineal pressure
Answer: C, D Rational: The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate. The client has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options A, B, and D are not specific assessment findings of the second stage of labor and occur in stage 1.
A client arrives at a birthing center in active labor. After examination, it is determined that the client's membranes are still intact, and the client is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? Select all that apply. A) Less pressure on the cervix. B) Decreased number of contractions. C) Increased efficiency of contractions. D) The need for increased maternal BP monitoring E) The need for frequent FHR monitoring to detect the presence of a prolapsed cord.
Answer: C, E Rational: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Rupturing of the membranes allows the fetal head to contract the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal BP is unnecessary after this procedure. The FHR needs to be monitored frequently, as there is an increase likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
The nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal heart monitor tracing. Which action is most appropriate? A) Notify the primary care provider of the findings. B) Reposition the client and check the monitor for changes in the fetal tracing. C) Take the client's vital signs and tell the client that bed rest is required to conserve oxygen. D) Document the findings and tell the client that the pattern on the monitor indicates fetal wellbeing.
Answer: D Rational: Accelerations are transient increases in the FHR that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal weel-being and adequate oxygen reserve. Options A, B, and C are inaccurate nursing actions and are unnecessary.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a C-section, what is the most important nursing action? A) Slow the intravenous flow rate B) Continue the oxytocin drip if infusing C) Place the client in a high fowlers position D) Administer oxygen, 8 to 10 L/minute, via face mask
Answer: D Rational: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option A is incorrect, because the intravenous infusion needs to be increased (per PHCP prescription) to increase the maternal blood volume. Option B is incorrect, because oxytocin stimulation of the uterus is discontinued if the FHR patterns change for any reason. Choice C is incorrect because the client is placed in the lateral position with the legs raised to increase maternal bllod volume and improve fetal perfusion.
The nurse in a birthing room is monitoring a client with dystocia for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? A) Maternal fatigue B) Coordinated uterine contractions C) Progressive changes in the cervix D) Persistent Non reassuring FHR
Answer: D Rational: Signs of fetal or maternal compromise include a persistent, non-reassuring FHR, fetal acidosis, and infection can occur of the labor is prolonged but do not indicate fetal or maternal compromise. Coordination uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if the client makes which statement? A) "I won't be in labor until the baby drops." B) "My contractions will be felt in my abdominal area." C) "My contractions will not be as painful if I walk around." D) "My contractions will last longer and be more intense."
Answer: D Rational: True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdomen are and contractions that ease with walking are signs of false labor.
