CH 21: Complications Occurring Before Labor & Delivery
PPROM (preterm premature rupture of membranes)
A rupture of membranes occurring before the start of contractions and before 37 weeks' gestation
What is chorioamnionitis?
Inflammation of the fetal membranes caused by infection; also known as intraamniotic infection.
What medication is always used as secondary or "piggyback"?
Oxytocin
what is aborization testing?
a sample of amniotic fluid is tested on a slide. Also known as Fern testing.
______is considered a surgical method of cervical ripening
amniotomy
placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus
vasa previa
occurs when the umbilical cord vessels cross the internal os of the cervix
placenta succenturiata
one or more accessory lobes connected to the main placenta by blood vessels
placental abruption
premature separation of the placenta
A ripe cervix is?
shortened
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? A) Premature separation of the placenta B) labor that was undiagnosed C) Placenta previa obstructing the cervix D) Possible fetal death or injury
A) Premature separation of the placenta Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.
A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client? A) Risk for fetal infection related to early rupture of membranes B) Hopelessness related to potential loss of pregnancy C) Anticipatory grieving related to high probability for fetal death from placental dysfunction D) Powerlessness related to inability to sustain pregnancy
A) Risk for fetal infection related to early rupture of membranes Once membranes have ruptured, the seal to the fetus is broken and microorganisms may infect the uterus or fetus. There is no indication in the scenario that a potential loss of pregnancy is evident, nor is there an indication of anticipatory grieving. As described in this scenario there is not a high probability of fetal death from placental dysfunction. A woman at 36 weeks' gestation would not be feeling powerless because of an inability to sustain pregnancy.
The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize? A) Vaginal bleeding and no pain B) Uterine contractions with vaginal mucus C) Fundal height and fetal heart rate D) Size and contour of the abdome
A) Vaginal bleeding and no pain Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of abruptio placentae accompanied by severe pain. This differentiates the two conditions. Uterine contractions with vaginal mucus may be indications of the start of labor with the mucous plug being discharged. The fetal heart rate, fundal height, and contour of the abdomen are normal components that are assessed during the labor process.
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 postterm pregnancy B) complications of preterm labor C) complications of placenta previa D) placental abruption
A) complications of a postterm pregnancy 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 pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? A) firm, rigid uterus on palpation B) bright red vaginal bleeding C) fetal heart rate within normal range D) absence of pain
A) firm, rigid uterus on palpation The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. Bright red vaginal bleeding is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.
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? Select all that apply. A) nifedipine B) magnesium sulfate C) dinoprostone D) misoprostol E) indomethacin
A) nifedipine B) magnesium sulfate E) indomethacin
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? A) uterine hyperstimulation B) headache C) blurred vision D) hypotension
A) uterine hyperstimulation 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. Headache, blurred vision, and hypotension are associated with magnesium sulfate.
When planning the care of a client scheduled for induction of labor with exogenous oxytocin, the nurse should make which asessment? A) fetal heart rate B) cervical ripening C) vaginal discharge D) fundal height
B) Cervical ripening The nurse should assess for cervical ripening before inducing labor with exogenous oxytocin. Oxytocin administration produces uterine contractions when the cervix is ripe. Cervical ripening indicates the presence of many oxytocin receptors. Exogenous oxytocin administration is ineffective when the cervix is unripe. Assessment of fetal heart rate is always important, but it is not a criteria for induction. Additionally, assessements of vaginal discharge and fundal height are not necessary prior to induction of labor with oxytocin.
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? A) Make sure the epidural medication is turned down. B) Check for a full bladder. C) Make sure the client is lying on her left side. D) Assess vital signs every 30 minutes.
B) Check for a 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.
The nurse would be alert for possible placental abruption during labor when assessment reveals which finding? A) macrosomia B) gestational hypertension C) gestational diabetes D) low parity
B) Gestational hypertension Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.
A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? A) Exercise helps reduce the frequency of them. B) If rhythmical, they could indicate preterm labor. C) Lying down for a few hours will help them stop. D) They are false labor and do not need to be reported.
B) 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.
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? A) Reticulocyte count B) Lecithin/sphingomyelin ratio C) Nitrazine test D) Test for antiphospholipids
B) 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. A reticulocyte count is used for testing sickle cell anemia. The nitrazine test aids in the diagnosis of PROM and differentiates the amniotic fluid that leaks out after PROM from the normal vaginal secretion. It does not aid in determining fetal lung maturity. A test for antiphospholipids is done in diagnosing antiphospholipids syndrome, and does not aid in determining fetal lung maturity.
A nurse is caring for a client at 30 weeks' gestation who had preterm premature rupture of membranes (PROM) 25 hours ago. The client has a temperature of 102°F (38.9°C) and a foul-smelling odor from the vagina. Which medication order should the nurse question? A) Ampicillin 1 GM IV B) Magnesium sulfate 2 GM IV/hr C) Tylenol 650 mg by mouth D) Erythromycin 500 mg IV
B) Magnesium sulfate 2 GM IV/hr Infection is a contraindication for tocolytic administration. The practitioner often orders a course of IV antibiotics (usually ampicillin and erythromycin for 48 hours), followed by oral antibiotics for 5 days to treat preterm PROM.
Bishop score
Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation, effacement, consistency, position, and station.
macrosomia
large-bodied baby commonly seen in diabetic pregnancies
Tocolysis
medications used to stop preterm labor
PROM (premature rupture of membranes)
A rupture of the amniotic membranes more than 1 hour before the onset of contractionsw
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? A) 11 B) 8 C) 6 D) 3
A) 11 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 client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used? A) 2 to 7 days B) 1 to 5 days C) 6 to 10 days D) 4 to 8 days
A) 2 to 7 days Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: A) 5. B) 6. C) 7. D) 9.
A) 5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.
A client has been admitted with abruptio placentae. 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? A) grade 2 B) grade 1 C) grade 3 D) grade 4
A) Grade 2 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.
A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which factor would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? A) aging of the placenta B) increased amniotic fluid volume C) meconium aspiration D) cord compression
B) increased amniotic fluid volume Fetal risks associated with a prolonged 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. All of these conditions predispose this fetus to birth trauma or a surgical birth. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths (Beacock, 2011). 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 by 40 weeks of 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 (Caughey & Butler, 2010).
A nurse is explaining to a group of nurses new to the labor and birth unit about about methods used for cervical ripening. The group demonstrates understanding of the information when they identify which method as a mechanical one? A) herbal agents B) laminaria C) membrane stripping D) amniotomy
B) laminaria Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical ripening. Herbal agents are a nonpharmacologic method. Membrane stripping and amniotomy are considered surgical methods.
A patient who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the patient that pelvic rest involves which of the following? A) staying in bed at all times B) placing nothing in the vagina C) staying in bed with bathroom privileges D) staying off of the feet the majority of the day
B) placing nothing in the vagina Pelvic rest is a situation in which nothing is placed into the vagina (including tampons and the practitioner's fingers to perform a cervical examination). The other options (strict bed rest and bed rest with bathroom privileges) also might be ordered when a woman has premature rupture of membranes.
A nurse is preparing an in-service program about labor and the hormones involved with the initiation of labor. Which information would the nurse include as believing to play a role in the onset of labor? A) suppression of prostaglandin release B) withdrawal of progesterone C) decrease in fetal cortisol levels D) supression of oxytocin
B) withdrawal of progesterone The onset of labor is believed to be due to a number of factors involving hormones. The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins. The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions. Changes in the ratio of estrogen to progesterone occurs, increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal.
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placentae and placenta previa. Which statement should the nurse include in the teaching? A) "Placenta previa causes painful, dark red bleeding during pregnancy due to an abnormally implanted placentae that is too close to or covers the cervix; abruptio placenta is associated with bright red painless bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." B) "Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." C) "Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the fundus; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." D) "Placenta previa causes painful, dark red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the fundus; abruptio placentae is associated with right red painless bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."
C) "Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the fundus; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless bright red bleeding in the third trimester. Abruptio placenta is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor.
A pregnant patient is prescribed to have labor induced with oxytocin. How should the nurse prepare to administer this medication? A) In a 20-cc bolus of saline B) In two divided intramuscular sites C) Diluted as a "piggyback" infusion D) Diluted in the main intravenous fluid
C) 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.
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? A) Amniotic fluid infection B) Amniotic fluid embolus C) Umbilical cord prolapse D) Placental abruption
C) 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.
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? A) "An IV line will assist the staff if your baby shows signs of distress." B) "Increasing your oxygen level will also increase the infant's oxygen level." C) "Changing your position to side lying can prevent hypotension from inferior vena cava compression." D) "Remember, the goal is to increase the FHR so a healthy infant can be born."
D) "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.
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 in a 20 cc bolus of saline. B) Administer oxytocin in two divided intramuscular sites. C) Administer oxytocin diluted in the main intravenous fluid. D) Administer oxytocin diluted as a "piggyback" infusion.
D) Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.
