NUAS240T - Chapter 21 - Nursing Management of Labor & Birth at Risk

a. Depressed deep tendon reflexes

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

b. Assess fetal heart sounds.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? a. Place the woman in Trendelenburg position. b. Assess fetal heart sounds. c. Administer amnioinfusion. d. Administer oxygen at 10 L/min by face mask.

b. McRoberts maneuver

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth? a. fundal pressure b. McRoberts maneuver c. Lamaze position d. positioning the woman prone

a. gestational diabetes

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which information would the nurse expect to find? a. gestational diabetes b. maternal rickets c. preterm pregnancy d. small body size of mother

d. increasing birth weight.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: a. longer lengths of labor. b. increased number of overall pregnancies. c. poor quality of prenatal care. d. increasing birth weight.

c. identical

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

d. administer oxygen by mask.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: a. tell the woman to take short, catchy breaths. b. increase her intravenous fluid infusion rate. c. put firm pressure on the fundus of her uterus. d. administer oxygen by mask.

a. preterm labor

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? a. preterm labor b. macrosomia c. normal labor d. dystocia

b. amniotic fluid embolism

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? a. placental separation b. amniotic fluid embolism c. congestive heart failure d. aspiration

c. Experience of additional back pain

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? a. Shorter dilatational stage of labor b. Need to have the baby manually rotated c. Experience of additional back pain d. Necessity for vacuum extraction for birth

d. "That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."

The nurse is preparing discharge instructions for a client at 32 weeks' gestation who was admitted for PROM. What is the best response from the nurse when the client asks when she can have intercourse with her husband again? a. "The need to keep the infant safe should be of more concern than when to have sex." b. "Intercourse has nothing to do with preterm labor; you can have sex with your husband." c. "You will not be able to have intercourse again until 6 weeks after you give birth." d. "That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."

d. potential lacerations and bleeding.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: a. damage to the maternal tissues. b. increased risk for cord entanglement. c. increased risk for uterine rupture. d. potential lacerations and bleeding.

b. cesarean birth

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? a. administration of morphine sulfate b. cesarean birth c. administration of oxytocin d. darkening room lights and decreasing noise and stimulation

d. Occiput posterior position

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

d. Placenta previa

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? a. Umbilical cord compression b. Uterine rupture c. Hypertonic uterus d. Placenta previa

c. precipitate labor

A client is told that she is already completely effaced and 9 cm dilated, and that the fetal head is showing. Contrary to the nurse's instructions, the client begins to push. Before the primary care provider can enter the room, the woman gives birth to the baby with only the nurse in attendance. This is an example of which occurrence? a. labor dystocia b. protraction disorder c. precipitate labor d. uterine dysfunction

d. transverse lie

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? a. cephalic presentation b. anterior fetal position c. occipitoposterior position d. transverse lie

b. administering oxytocin

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client? a. providing a comfortable environment with dim lighting b. administering oxytocin c. preparing the woman for an amniotomy d. encouraging the woman to assume a hands-and-knees position

d. The parents are beginning to demonstrate positive grieving behaviors.

A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? a. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn. b. The parents continue to mourn the loss of their infant. c. The parents just cannot believe their perfect infant died. d. The parents are beginning to demonstrate positive grieving behaviors.

d. Administer oxytocin diluted as a "piggyback" infusion.

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 two divided intramuscular sites. b. Administer oxytocin in a 20 cc bolus of saline. c. Administer oxytocin diluted in the main intravenous fluid. d. Administer oxytocin diluted as a "piggyback" infusion.

b. place a hand gently on the fetal head to guide birth.

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 to: a. ask her to push with the next contraction so birth is rapid. b. place a hand gently on the fetal head to guide birth. c. attach a fetal monitor to determine fetal status. d. assess blood pressure and pulse to detect placental bleeding.

b. Offer to take pictures and footprints of the infant once it is delivered.

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? a. Recommend that she not hold the infant after it is delivered so as to not upset her more. b. Offer to take pictures and footprints of the infant once it is delivered. c. Call the hospital chaplain to talk to the parents. d. Explain to her that there was probably something wrong with the infant and that is why it died.

a. assess the rate of flow of the oxytocin infusion.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: a. assess the rate of flow of the oxytocin infusion. b. administer oral orange juice for added potassium. c. instruct her to breathe in and out rapidly. d. assess her vaginally for full dilation.

c. Turn off the oxytocin.

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? a. Turn off the methotrexate. b. Increase the methotrexate. c. Turn off the oxytocin. d. Increase the oxytocin.

a. Placental abruption

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? a. Placental abruption b. Genetic abnormality c. Preeclampsia d. Premature rupture of membranes

c. 45 ml urine output in 2 hours

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider? a. hematocrit of 36% b. hemoglobin of 13 g/dl c. 45 ml urine output in 2 hours d. platelet count of 150,000 mm3

e. less than 3 hours

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? a. less than 8 hours b. less than 4 hours d. less than 5 hours e. less than 3 hours

c. An emergency cesarean birth

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

d. Cervix dilates 1 cm per hour.

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? a. Cervix dilates 2 cm per hour. b. Fetus descends 2 cm per hour. c. Fetus descends 1 cm per hour. d. Cervix dilates 1 cm per hour.

b. A full bladder or rectum can impede fetal descent.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? a. If the woman's bladder is distended, it may rupture. b. A full bladder or rectum can impede fetal descent. c. A full rectum can cause diarrhea. d. If the woman has a full bladder, labor may be uncomfortable for her.