Durham, Chapter 10 High-Risk Labor and Birth

The first sign of shoulder dystocia is the ____________________ of the fetal head against the maternal perineum after delivery of the head.

retraction Feedback: Shoulder dystocia is an unpredictable and unpreventable obstetric emergency that places the laboring mother and neonate at risk of injury and complications. The anterior shoulder or, more rarely, both shoulders become impacted above the pelvic rim. The first sign is a retraction of the fetal head against the maternal perineum after delivery of the head, sometimes referred to as turtle sign.

The nurse is providing care to a patient who is at 41 weeks gestation. Which factor about the patient does the nurse consider as an indication of late-term or post-term pregnancy? 1. Fetus is identified as a male 2. Patient's multiparity status 3. Delivered two babies at 38 weeks 4. History of regular menstruation

Ans 1 Feedback 1 This is correct. Several risk factors for post-term pregnancy have been identified, including carrying a male fetus. 2 This is correct. The patient's multiparity status is not a factor related to postterm pregnancy. A history of post-term pregnancy is an identified risk factor. 3 This is correct. Having delivered two previous pregnancies at 38 weeks gestation is not an identified risk factor for a post-term pregnancy. 4 This is incorrect. A history of irregular menstruation may contribute to miscalculation about fetal age; a regular menstruation history is not a risk factor

The nurse is providing care for a patient in the second phase of labor. After more than 4 hours of pushing, the nurse suspects fetal dystocia. Which is the greatest risk related to the nurse's suspected complication? 1. Neonatal asphyxia related to prolonged labor 2. Fetal injury confirmed by the presence of bruising 3. Greater risk for maternal lacerations 4. Increased consideration for a cesarean delivery

Ans 1 Feedback 1 This is correct. The greatest concern related to fetal dystocia is the complication of fetal asphyxia related to a prolonged labor. 2 This is incorrect. With fetal dystocia, the complication of fetal injury is possible and may be evidenced by the presence of bruising. 3 This is incorrect. A complication of fetal dystocia is a greater risk for maternal lacerations. 4 This is incorrect. The complication is fetal dystocia; a possible solution to the condition is cesarean delivery of the fetus.

A patient arrives at labor and delivery for the induction labor for her first child. The patient tells the nurse, "I can't believe how easy this is just to pick a day, sign a paper, and have a baby." Which action does the nurse take before the induction process? 1. Call the health care provider to validate patient understanding. 2. Check the patient's chart for an informed consent. 3. Explain the possible complications of induction to the patient. 4. Report an incidence of probable malpractice by the health care provider.

Ans 1 Feedback 1 This is correct. The nurse needs to call the health care provider and validate patient understanding about potential risks and complications related to labor induction. 2 This is incorrect. The nurse can check the patient's chart for a signed consent; however, the patient verbally states a paper was signed. There is a more appropriate nursing action. 3 This is incorrect. It is not within the scope of nursing for the nurse to explain possible complications of any procedure to a patient. Medical information can be reinforced by the nurse. 4 This is incorrect. It is not appropriate at this time to report a probable malpractice incidence. The nurse has an obligation to contact the health care provider.

During a vaginal delivery, the primary care provider notices greenish yellow coloration on the fetal head during crowning. Intrapartum suctioning is performed as soon as the fetus's head is delivered. The nurse understands the aspiration of meconium will have which effects on the neonate's respiratory function? Select all that apply. 1. Result in airway obstruction 2. Contribute to pulmonary hypertension 3. Result in chemical pneumonitis 4. Cause surfactant dysfunction 5. Create strain on cardiac function

Ans 1, 2, 3, 4 Feedback 1 This is correct. Meconium aspiration syndrome (MAS) will result in airway obstruction, which is relative to the amount and consistency of the aspirated meconium. 2 This is correct. Due to airway obstruction related to MAS, there is a high risk for the development of pulmonary hypertension. 3 This is correct. Chemical pneumonitis is inflammation of the bronchial structures of the lungs caused by chemicals and/or substances that are foreign to the lungs. The presence of meconium or the medications used to treat MAS could be sources for the condition. 4 This is correct. If the meconium is aspirated deeply enough, the air sacs may be coated with the aspirate, which will interfere with the functioning of surfactant. 5 This is incorrect. The question specifically asks for identification of MAS on the fetus/neonate's respiratory function

When assisting with a vacuum-assisted vaginal delivery, the nurse is aware that adherence to which guidelines for the vacuum device will minimize the nurse's liability in vacuum-assisted vaginal births? Select all that apply. 1. Pump up the vacuum manually to the pressure indicated on the pump. 2. Recognize that cup detachment (pop off) is a warning sign. 3. Understand that pressure should be released between contractions. 4. The procedure is timed from insertion of the cup into the vagina until the birth. 5. The cup should not be on the fetal head for longer than 5 to 10 minutes.

Ans 1, 2, 3, 4 Feedback 1 This is correct. Pump up the vacuum manually to the pressure indicated on the pump, not to exceed 500 to 600 mm Hg. 2 This is correct. The nurse needs to be aware that cup detachment (pop off) is a warning that too much ineffective force is being exerted on the fetal head. 3 This is correct. It is important to understand that pressure should be released between contractions; retention of unnecessary pressure increases the risk for fetal injury. 4 This is correct. The procedure is timed from point of insertion of the cup into the vagina until the birth. If the vacuum-assisted delivery does not occur after three attempts within 15 to 20 minutes, cesarean is indicated. 5 This is incorrect. The cup should not be on the fetal head for longer than 15 to 20 minutes. The nurse needs to be the reminder of the "three-pull rule" that specifies that vacuum-assisted efforts need to be stopped after three attempts in 15 minutes.

A patient in labor receives high-level regional anesthesia, which inhibits her ability to push during the second state of labor. The primary care provider will use forceps to aid in the delivery of the fetus. Which fetal complications is the nurse aware of being related to a forceps birth? Select all that apply. 1. Intracranial hemorrhage 2. Cephalohematoma 3. Nerve injuries 4. Skin lacerations 5. Skull fracture

Ans 1, 2, 3, 4, 5 Feedback 1 This is correct. Intracranial hemorrhage is a possible complication of a forceps delivery and results from pressure on the fetal head by the forceps during birth. 2 This is correct. Cephalohematoma is a possible complication of a forceps delivery and results from pressure on the head, which causes the rupture of small blood vessels and the collection of blood beneath the scalp. 3 This is correct. Nerve injuries are a possible complication of a forceps delivery and result from the pulling action of moving the fetus down the birth canal. 4 This is correct. Skin lacerations are a possible complication of forceps delivery and result primarily during the insertion of the forceps. 5 This is correct. Skull fracture is a possible complication of a forceps delivery and results from pressure on the fetal skull during insertion of the forceps and/or when exerting pressure during extraction of the fetus.

A patient at 34 weeks gestation is in labor with twins. The primary care provider decides the fetuses need to be delivered by cesarean. Which medical and nursing interventions will be in place for this delivery? Select all that apply. 1. Delivery is attended by two medical personnel. 2. The placement of a large-bore IV access is ensured. 3. The usual personnel to attend delivery is arranged. 4. A hospital with a Level II or III nursery is selected. 5. The FHR for the two fetuses is monitored alternately.

Ans 1, 2, 4 Feedback 1 This is correct. For multiple births, either two experienced obstetricians or one obstetrician and a board-certified midwife will attend the delivery. 2 This is correct. The nurse will make sure that a large-bore IV access is in place for fluid replacement in case of hemorrhage or need for emergency fluid replacement and anesthesia administration. 3 This is incorrect. For the delivery of multiple fetuses, the usual personnel for surgery will be required. Personnel will include an anesthesia provider, a scrub nurse, and a circulating nurse. 4 This is correct. Due to the possibilities of fetal distress or need of special care related to immaturity, the cesarean needs to be performed in a hospital with either a Level II or III nursery. 5 This is incorrect. The nurse will continue to monitor both fetuses simultaneously and continuously. Once membranes are ruptured, internal monitoring for twin A is initiated. The well-being of one twin does not ensure the well-being of the other twin.

The nurse is providing care for a patient who is at 42 weeks gestation. The patient's primary care provider is suggesting induction, but the patient is resistant. Which facts can the nurse provide if the patient asks about allowing labor to start spontaneously? Select all that apply. 1. Stillbirth or newborn death increases in pregnancies beyond 42 weeks. 2. There is a greater chance of developing complications because of larger fetal size. 3. Maternal death rate is higher if the pregnancy is continued beyond 42 weeks. 4. Post-term fetuses are prone to developmental delays related to uterine hypoxia. 5. Postmature fetuses have decreased subcutaneous fat and lack vernix and lanugo

Ans 1, 2, 5 Feedback 1 This is correct. One of the greatest concerns about post-term pregnancy is the increased risk of stillbirth or infant death. 2 This is correct. The fetus who is post-term is most likely to exhibit macrosomia, a condition that contributes to a higher risk for complications associated with both the mother and fetus. 3 This is incorrect. There is no support for a higher maternal death rate related to postterm pregnancies. 4 This is incorrect. There is no definitive connection between post-term pregnancies and developmental delays in the child born post-term. 5 This is correct. Postmature fetuses have decreased subcutaneous fat and lack vernix and lanugo. However, although the nurse can present this as factual information, it is likely to have little influence on the patient's decision.

The nurse is providing care to a patient who is in labor. The patient's membranes rupture spontaneously, and the nurse notices meconium-stained amniotic fluid. Which actions does the nurse immediately perform? Select all that apply. 1. Alert the neonatal team of a possible meconium aspiration neonate. 2. Promote fetal well-being by placing the patient on her left side. 3. Test the stained fluid for percentage of meconium content. 4. Administer oxygen to the mother to help prevent fetal hypoxia. 5. Notify the primary care provider about the presence of meconium.

Ans 1, 5 Feedback 1 This is correct. The nurse will immediately inform the neonatal resuscitation team that they may expect a meconium aspiration neonate. It is imperative that resuscitation occur immediately in order to avoid or decrease respiratory complications. 2 This is incorrect. The nurse will need to monitor for fetal well-being since the presence of meconium in the amniotic fluid can be indicative of fetal distress. However, placing the patient on her left side is not necessary. 3 This is incorrect. There is no reason for or means to test the amniotic fluid to determine the percentage of meconium. All infants with meconium in the amniotic fluid should have their nose, mouth, and pharynx suctioned as soon as the head is delivered (intrapartum suctioning) regardless of whether the meconium is thin or thick. 4 This is incorrect. Administering oxygen to the patient may or may not be necessary. Fetal monitoring is performed to help identify any indications of fetal hypoxia. 5 This is correct. The nurse immediately notifies the primary care provider about the meconium-stained amniotic fluid, which may be an indicator of fetal distress.

A patient who is pregnant expresses a desire to attempt a vaginal delivery after a cesarean birth 2 years before. The primary care provider initiates trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (CVAC) screening. The nurse is aware that which patient information will likely disqualify the patient for CVAC? 1. A low transverse uterine scar 2. Cesarean due to pelvic abnormalities 3. First labor needed to be induced 4. Patient asks multiple questions

Ans 2 Feedback 1 This is incorrect. A low transverse uterine scar is the safest for TOLAC/CVAC. 2 This is correct. The fact that the patient had a cesarean for pelvic abnormalities will disqualify her for TOLAC/CVAC; pelvic abnormalities are permanent. 3 This is incorrect. When the first labor is induced, the second birth may also need induction; however, this information does not disqualify the patient for TOLAC/CVAC. 4 This is incorrect. The patient considering TOLAC/CVAC is making a decision about both her safety and the safety of her fetus. Asking multiple questions is not a reason to disqualify the patient from TOLAC/CVAC.

The nurse in labor and delivery is preparing to initiate labor induction with the administration of oxytocin. After research about oxytocin, the nurse is aware of which fact about the drug? 1. Hypothalamus stimulation increases circulating oxytocin. 2. Synthetic oxytocin is identical to endogenous oxytocin. 3. The half-life of oxytocin is 1 hour, supporting close monitoring. 4. Action from IV oxytocin administration is less than 1 minute.

Ans 2 Feedback 1 This is incorrect. Labor induction is not a result of endogenous oxytocin, which is a peptide synthesized by the hypothalamus that is transported to the posterior lobe of the pituitary gland. Oxytocin is naturally released in response to vaginal and cervical stretching. 2 This is correct. The nurse is aware from drug research that synthetic oxytocin is identical to endogenous oxytocin. 3 This is incorrect. The administration of oxytocin does require close monitoring, but the half-life of the drug is 10 minutes, not 1 hour. 4 This is incorrect. Uterine response to oxytocin usually occurs within 3 to 5 minutes after IV administration begins.

The nurse is attending to a patient who just delivered a term fetus who was stillborn. Which nursing interventions will the nurse use to provide emotional support to the couple? Select all that apply. 1. Express the belief that a little angel was sent to heaven. 2. Cut a lock of the neonate's hair and get foot and hand prints. 3. Ask the parents what name they are giving their baby. 4. Inquire if the patient had any warning of fetal death. 5. Allow parents unlimited time to hold and touch the neonate.

Ans 2, 5 Feedback 1 This is incorrect. It is important for health care professionals to not use any clichés that belittle the situation. 2 This is correct. The parents need to have mementoes of the baby. Items may include photographs of the infant, locks of hair, name bracelets, footprints, measuring tape, name certificates, quilts, clothing, poems, or sympathy cards. 3 This is incorrect. Nurses can build trust with the women and families they care for while keeping in mind that decisions made are based on each woman's or family's unique cultural and individual identity. Some parents may name the neonate and arrange for specific rituals. 4 This is incorrect. Helping grieving families includes listening more than talking, allowing for silence, being genuine and caring, allowing them to express their feelings, and listening to their story without passing judgment. Asking the patient about warning signs of fetal death may foster feelings of guilt. 5 This is correct. The neonate is wrapped in a blanket and given to the parents to hold and touch for as long as they wish. Other family members may be included as the parents wish.

The nurse is providing care to a patient who is diagnosed with dystocia related to hypertonic uterine dysfunction. Which medical intervention does the nurse implement for this patient? 1. Explain to the family that the patient needs rest before labor continues. 2. Assist the patient to relax by providing back and neck massage. 3. Administer morphine to decrease contractions and promote uterine rest. 4. Discuss how the patient's fear is interfering with the progression of labor

Ans 3 Feedback 1 This is incorrect. Explaining to the family that the patient needs rest is applicable; however, this action is not considered a medical intervention. 2 This is incorrect. A back and neck massage may help the patient to relax; however, this action is not considered a medical intervention. The patient may also benefit from a warm shower or tub bath, a quiet environment, and a long period of sleep. 3 This is correct. The medical intervention of administering a pain medication, such as morphine, will decrease uterine contractions and allow the uterus to rest. 4 This is incorrect. In this scenario, the patient's dystocia is not related to fear. Hypertonic uterine dysfunction is uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement

A patient who is at 39 weeks gestation is scheduled for amniotomy. The nurse is aware that which criteria must be met before the procedure? 1. Ultrasound indicates the umbilical cord is away from the cervix. 2. The nurse must have certification to perform the procedure. 3. The fetal head is currently engaged in the maternal pelvis. 4. Prior amniotic fluid leakage must be validated before the procedure.

Ans 3 Feedback 1 This is incorrect. A possible complication with amniotomy is for prolapse of the umbilical cords, and careful monitoring is required. However, the placement of the cord is not identified by ultrasound before the procedure. 2 This is incorrect. The amniotomy is performed by the primary health care provider who needs to be available in the event that an emergency intervention is necessary. Nurses do not perform this procedure. 3 This is correct. An important criterion for performing an amniotomy is for the fetal head to be engaged in the maternal pelvis. Lack of engagement will result in a prolonged labor and/or an increased risk for infection. 4 This is incorrect. Amniotic fluid leakage does not need to be confirmed before an amniotomy.

The nurse is teaching a prenatal class. For which reason does the nurse emphasize the importance of managing maternal fear during labor? 1. Fear promotes feelings of exhaustion. 2. Mothers cannot enjoy the actual birth. 3. Dystocia is associated with extreme fear. 4. Fear during labor causes postpartum depression.

Ans 3 Feedback 1 This is incorrect. Fear and exhaustion are often experienced together by the patient in labor. However, there is a more important reason to focus on fear. 2 This is incorrect. The nurse will focus on the physiological impact of fear during labor rather on the extent to which a patient will enjoy the birthing process. 3 This is correct. Extreme maternal fear or exhaustion can result in catecholamine release interfering with uterine contractility, a condition that will cause dystocia. 4 This is incorrect. Postpartum depression is related to hormonal changes after birth.

The nurse is providing care for a primip patient in active labor. Cervical dilation has progressed 0.5 cm in 2 hours. Intrauterine pressure catheter reading is 20 mm Hg. Which action does the nurse anticipate next? 1. Rupture of uterine membranes by the nurse 2. Preparation for a cesarean delivery due to signs of fetal distress 3. Augmentation of labor with oxytocin per health care provider's order 4. Medicating the patient with pain medication to promote uterine rest

Ans 3 Feedback 1 This is incorrect. Rupture of the uterine membranes can improve dystociarelated hypotonic uterine dysfunction; however, this is not a nursing action. The health care provider will rupture the membranes and react accordingly if umbilical cord prolapse or fetal distress occurs. In this scenario, the membranes are likely ruptured because of the use in an intrauterine pressure catheter. 2 This is incorrect. A cesarean birth may be necessary; however, other actions to resolve the hypotonic uterine dysfunction will be tried first unless there is fetal distress. 3 This is correct. The action the nurse will anticipate is the augmentation of labor with administration of the prescribed oxytocin. 4 This is incorrect. Medicating the patient with pain medication to promote uterine rest is not an appropriate action for a patient with hypoactive uterine dysfunction. This is an appropriate action for the patient with hyperactive uterine dysfunction.

The nurse is providing care for a patient who is admitted for cervical ripening. The health care provider has prescribed the use of a hygroscopic dilator. Which conclusion is the nurse likely to draw from the prescribed method of cervical ripening? 1. This method is quicker than hormonal ripening. 2. The patient has a history of cesarean childbirth. 3. The method may be indicative of fetal demise. 4. This patient is being treated for active herpes.

Ans 3 Feedback 1 This is incorrect. The process of cervical ripening using a hygroscopic dilator occurs over a period of 12 to 24 hours as the inserted material absorbs water. 2 This is incorrect. Hydroscopic dilators for cervical ripening are not used specifically for women who have a history of cesarean childbirth. Pharmacological ripening can be achieved through the use of Cervidil. Misoprostol is avoided with a patient with a history of cesarean due to the risk of uterine rupture. 3 This is correct. Currently, hygroscopic dilators are used primarily during pregnancy termination rather than for cervical ripening in term pregnancies. Pregnancy termination may be necessary due to fetal demise. 4 This is incorrect. Being treated for active herpes is a contraindication for any method of cervical ripening. The patient with active herpes will require a cesarean delivery.

The nurse is assisting the primary care provider with a vacuum-assisted delivery because of a prolonged second stage of labor. The nurse will inform the primary care provider when which guideline of the procedure is met? 1. Extension of the episiotomy is performed. 2. Signs of fetal compromise have resolved. 3. Patient is under full anesthesia status. 4. The "three-pull rule" has been achieved.

Ans 4 Feedback 1 This is incorrect. Extension of the patient's episiotomy is not a guideline for performance of vacuum-assisted delivery. 2 This is incorrect. A vacuum-assisted delivery is performed in the presence or suspicion of immediate or potential fetal compromise. Stopping the procedure for resolved fetal compromised is not a guideline for vacuum-assisted delivery. 3 This is incorrect. One advantage to vacuum-assisted delivery is a decrease in the amount of anesthesia required for the patient. 4 This is correct. The nurse will inform the care provider when the "three-pull rule" guideline for vacuum-assisted delivery has be achieved. There should be a maximum of three attempts for a period of 15 minutes.

The terminology intrauterine inflammation or infection or both or Triple I is now used instead of the term ____________________.

Chorioamnionitis Feedback: Given the historical inconsistency in use, experts proposed to discontinue the intrapartum use of the term chorioamnionitis and instead use intrauterine inflammation or infection or both or Triple I. The term intraamniotic infection is commonly used since infectio