Chapter 8 - Nursing Care of Women with Complications During Labor and Birth

A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause?

a. Prolonged pressure against the partially dilated cervix.

b. Small leak of fluid through the posterior fontanelle.

c. Pressure of the forceps during delivery.

d. The effect of the vacuum extractor.

Answer: d. The effect of the vacuum extractor.

Rationale: The chignon is due to the effect of the vacuum extractor and will disappear in a few days.

A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief?

a. Prone with legs supported and give her a back massage.

b. Supine with legs bent at the knee.

c. Standing with support.

d. Sitting up and leaning forward on the over-bed table.

Answer: d. Sitting up and leaning forward on the over-bed table.

Rationale: A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor?

a. Get an order for an intravenous narcotic.

b. Notify the anesthesiologist for an epidural block.

c. Stay and breathe with her during contractions.

d. Tell her to bear with it because she is close to delivery.

Answer: c. Stay and breathe with her during contractions.

Rationale: The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient?

a. Chorioamnionitis

b. Hemorrhage

c. Hypotension

d. Amniotic fluid embolism.

Answer: a. Chorioamnionitis

Rationale: Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

Which statement indicates a woman understands activity limitations for the management of preterm labor?

a. After my shower in the morning, I do the laundry and straighten up the house; then I rest.

b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.

c. I have a 2-year-old to care for, but I try to rest as much as I can.

d. I get really bored at home, so I go to the shopping mall for just a little while.

Answer: b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.

Rationale: Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response?

a. The fundus is not assessed until the second postoperative day.

b. The fundus is assessed by walking fingers from the side of the uterus to the midline.

c. The fundus is assessed only if large clots appear in lochia.

d. The fundus is assessed only once every shift.

Answer: b. The fundus is assessed by walking fingers from the side of the uterus to the midline.

Rationale: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord?

a. On her right side with knees flexed.

b. On her left side with a pillow placed between her legs.

c. On her back with her head lower than the rest of her body.

d. Supine with her legs elevated and bent at the knee.

Answer: c. On her back with her head lower than the rest of her body.

Rationale: The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis?

a. Anxiety related to the development of postpartum complications.

b. Ineffective individual coping related to unfamiliarity with procedures.

c. Risk for ineffective parenting related to emergency cesarean section.

d. Grieving related to loss of expected birth experience.

Answer: d. Grieving related to loss of expected birth experience.

Rationale: Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do?

a. Report any increase in fetal activity.

b. Notify her obstetrician if she has a temperature above 37.8 C (100 F).

c. Massage her breasts to promote uterine relaxation.

d. Rest in a side-lying Trendelenburg position with hips elevated.

Answer: b. Notify her obstetrician if she has a temperature above 37.8 C (100 F).

Rationale: For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F).

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience?

a. Nausea and vomiting.

b. Headache.

c. Warm flush.

d. Urinary frequency.

Answer: c. Warm flush.

Rationale: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor?

a. By decreasing a woman's pain sensitivity.

b. By reducing blood flow to the uterus.

c. By increasing the ability to tolerate pain.

d. By enhancing maternal pushing through greater muscle tension.

Answer: b. By reducing blood flow to the uterus.

Rationale: Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action?

a. Give the pain remedy.

b. Notify the charge nurse immediately.

c. Turn the patient to her back and flex her knees.

d. Suggest that the coach give her a back rub.

Answer: b. Notify the charge nurse immediately.

Rationale: Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration?

a. Prevent infection.

b. Increase fetal lung maturity.

c. Increase blood flow from placenta.

d. Relax the cervix.

Answer: b. Increase fetal lung maturity.

Rationale: Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first?

a. 18-year-old primigravida with a fetal breech presentation.

b. 25-year-old multigravida with history of previous cesarean section.

c. 35-year-old multigravida with history of precipitate birth.

d. 16-year-old primigravida with a twin pregnancy.

Answer: c. 35-year-old multigravida with history of precipitate birth.

Rationale: A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient?

a. Elevated uterine resting tone.

b. Painful and poorly coordinated contractions.

c. Implementation of fluid restriction.

d. Use of frequent position changes.

Answer: d. Use of frequent position changes.

Rationale: A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.)

a. Oral temperature of 37 C (99.8 F).

b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute.

c. Flecks of vernix in the amniotic fluid.

d. Low back pain.

e. Edematous labia.

Answer: b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute.

Rationale: Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the other options are normal findings for late pregnancy.

What are the rationales for labor induction? (Select all that apply.)

a. Placenta previa.

b. Prolapse of cord.

c. High station of fetus.

d. Maternal diabetes.

e. Placental insufficiency.

Answer: D, E

Rationale: Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction.

Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.)

a. Encouraging the patient to sit upright.

b. Assisting the patient to ambulate.

c. Stimulating the nipples.

d. Offering emotional support.

e. Allowing the patient to vent frustration.

Answer: A, B, C

Rationale: Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor.

What complications of overstimulation of uterine contractions may occur? (Select all that apply.)

a. Water intoxication.

b. Impaired placental exchange of oxygen and nutrients.

c. Increased blood pressure.

d. Convulsions.

e. Uterine rupture.

Answer: A, B, E

Rationale: The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.)

a. Place a warm, moist washcloth over the breast.

b. Brush the nipples with a dry washcloth.

c. Gently pull on the nipples.

d. Apply suction to the nipples with a breast pump.

e. Press the palms of her hands down on her breasts.

Answer: B, C, D

Rationale: Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions.

A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.)

a. Maternal gynecoid pelvis.

b. Placenta previa.

c. Horizontal cesarean incision.

d. Prolapsed cord.

e. Gestational diabetes.

Answer: B, D

Rationale: Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvis is the most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction.

A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.)

a. Insert IV.

b. Record a baseline fetal heart rate.

c. Explain procedure to patient.

d. Instruct patient to ambulate immediately afterward.

e. Ensure a tocolytic is available.

Answer: A, B, C

Rationale: The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.

Answer: amnioinfusion

Rationale: A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.

_____________________________ is a lower-than-normal amount of amniotic fluid.

Answer: Oligohydramnios

Rationale: Oligohydramnios is a lower amount than normal of amniotic fluid.

A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions.

Answer: laminaria

Rationale: A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.