Chapter 19 Nursing care during Obstetric Procedures

The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. The correct rationale for this intervention is that:

a.

a sterile urine specimen is needed preoperatively.

b.

an empty bladder provides more room in the pelvis.

c.

spontaneous release of urine might contaminate the sterile field.

d.

a Foley catheter prevents the membranes from spontaneously rupturing.

B- an empty bladder provides more room in the pelvis

After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

a.

Lack of an episiotomy

b.

Mild, intermittent perineal pain

c.

Lack of pain in the perineal area

d.

Edema and discoloration of the labia and perineum

D- Edema and discoloration of the labia and perineum

The nurse is positioning the Foley catheter prior to a cesarean birth. Which position should the nurse use to place the catheter drainage tubing and catheter bag?

a.

Place near the head of the table.

b.

Position on top of the patients leg.

c.

Place at the foot and clamp during the cesarean section.

d.

Position at the foot of the surgeon under the sterile drapes.

A- Place near the head of the table

Which condition is a contraindication for an amniotomy?

a.

2 station

b.

Breech presentation

c.

Dilation less than 3 cm

d.

Right occiput posterior position

A- 2 Station

Which client status is an acceptable indication for serial oxytocin induction of labor?

a.

Multiple fetuses

b.

Polyhydramnios

c.

History of long labors

d.

Past 42 weeks of gestation

D- Past 42 weeks of gestation

The nurse is explaining the technique of internal version to a group of nursing students. Which describes the technique of internal version?

a.

Manipulation of the fetus from a breech to a cephalic presentation before labor begins

b.

Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth

c.

Manipulation of the second twin from an oblique lie to a transverse lie before labor begins

d.

Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

D- Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

The greatest risk to the newborn after an elective cesarean birth is:

a.

tachypnea because of maternal anesthesia.

b.

tachycardia because of maternal narcotics.

c.

trauma because of manipulation during birth.

d.

prematurity because of miscalculation of gestation.

D- Prematurity because of a miscalculation of gestation

Which client is most at risk for a uterine rupture?

a.

A gravida 4 who had a classic cesarean incision

b.

A gravida 5 who had two vaginal births and one cesarean birth

c.

A gravida 3 who has had two low-segment transverse cesarean births

d.

A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

A- A gravida 4 who had a classic cesarean incision

Before the health care provider performs an external version, the nurse should expect an order for a:

a.

Foley catheter.

b.

tocolytic drug.

c.

local anesthetic.

d.

contraction stress test (CST).

B- tocolytic drug

A maternal indication for the use of vacuum extraction is:

a.

a wide pelvic outlet.

b.

maternal exhaustion.

c.

a history of rapid deliveries.

d.

failure to progress past 0 station.

B- Maternal exhaustion

The priority nursing intervention following an amniotomy is to:

a.

change the clients gown.

b.

assess the fetal heart rate.

c.

assess the color of the amniotic fluid.

d.

estimate the amount of amniotic fluid.

B- assess the fetal heart rate

For which client should the oxytocin (Pitocin) infusion be discontinued immediately?

a.

A client in transition with contractions every 2 minutes lasting 90 seconds each

b.

A client in early labor with contractions every 5 minutes lasting 40 seconds each

c.

A client in active labor with contractions every 3 minutes lasting 60 seconds each

d.

A client in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each

A- a client in transition with contractions every 2 minutes lasting 90 seconds each

The priority nursing care associated with an oxytocin infusion is:

a.

measuring urinary output.

b.

evaluating cervical dilation.

c.

monitoring uterine response.

d.

increasing infusion rate every 30 minutes.

C- Monitoring uterine response

Which event indicates a complication of an external version?

a.

Maternal pulse rate of 100 bpm

b.

Fetus returning to the original position

c.

Increased maternal anxiety after the version

d.

Fetal bradycardia persisting 10 minutes after the version

D- Fetal bradycardia persisting 10 minutes after the version

Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?

a.

Assess the infant for signs of trauma.

b.

Apply a cold pack to the infants scalp.

c.

Give the infant prophylactic antibiotics.

d.

Measure the circumference of the infants head.

A- Assess the infant for signs of trauma

Nursing care before a cesarean birth should include:

a.

full perineal shave preparation.

b.

administering a clear oral antacid.

c.

injection of narcotic preoperative medications.

d.

straight catheterization to empty the bladder.

B- Administering a clear oral antacid

A gravida 2, para 1 client is admitted to the labor and birth unit in labor. She states that she had a cesarean birth with her first pregnancy. The most critical information the nurse must obtain at this point is:

a.

the onset of contractions.

b.

her estimated date of birth.

c.

when the client ate last and what she consumed.

d.

the type of uterine incision with the first pregnancy.

D- the type of uterine incision with the first pregnancy

Which is an appropriate response to a clients comment that she is worried about having a cesarean birth?

a.

Dont worry. Everything will be okay.

b.

Clients commonly worry about surgery.

c.

What are your feelings about having a cesarean birth?

d.

I know youre worried, but this is a routine procedure.

C- What are your feelings about having a cesarean birth?

While assisting with a vacuum extraction birth, which should the nurse immediately report to the physician?

a.

Maternal pulse rate of 100 bpm

b.

Maternal blood pressure of 120/70 mm Hg

c.

Persistent fetal bradycardia below 100 bpm

d.

Decreased intensity of uterine contractions

C- Persistent fetal bradycardia below 100 bpm

To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement?

a.

Monitor her urinary output.

b.

Maintain an intravenous infusion at 1 mL/hr.

c.

Assess the abdominal dressings for drainage.

d.

Assess the uterus for firmness every 15 minutes.

D- assess the uterus for firmness every 15 minutes

The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of a client. With which client should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?

a.

The client who has a Bishops score of 5

b.

The client who is at 42 weeks of gestation

c.

The client who had a previous low transverse cesarean birth

d.

The client who had previous surgery in the upper uterus

D- The client who had previous surgery in the upper uterus

A vaginal exam for a laboring multipara client who is 42 weeks gestation reveals the following information: 4 cm, minimal effacement, 2 station. Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook?

a.

Vaginal dilation

b.

Client is a multipara

c.

Presenting part is at 2 station

d.

Gestational age

D- Gestational age

A client who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority?

a.

Increase rate of Pitocin infusion to help spread out contraction pattern.

b.

Place oxygen on client at 8 to 10 L/min via face mask and turn client to left side.

c.

Stop Pitocin infusion.

d.

Call physician to obtain an order for initiation of magnesium sulfate.

C- Stop the pitocin infusion

Which clinical finding indicates the use of vacuum extraction as a birth method?

a.

Mentum presentation of the fetus

b.

Presence of caput succedaneum

c.

Maternal exhaustion as a result of ineffective pushing during second stage of labor

d.

Physician preference

C- Maternal exhaustion as a result of ineffective pushing during the second stage of labor

Which of the following factors would lead to an increased risk for a prolapsed cord to occur during an amniotomy?

a.

Presenting part engaged

b.

Postdated pregnancy

c.

Preterm pregnancy

d.

Term pregnancy

C- Preterm pregnancy

A client is being sent into the labor and birth unit for a serial induction of labor. The Bishops score is 7. What would the nurse anticipate as the sequence of treatment planned for this client?

a.

Administration of laminaria with EFM followed by amniotomy and oxytocin (Pitocin) infusion in a 12-hour period

b.

Amniotomy on the first day in conjunction with EFM followed by oxytocin (Pitocin) infusion on the following clinical day

c.

Administration of oxytocin (Pitocin) on the first day followed by amniotomy on the second clinical day

d.

Administration of laminaria with EFM on the first day followed by oxytocin (Pitocin) infusion on the second day and evaluation of progress; on the third day, continued oxytocin (Pitocin) infusion with amniotomy

D- Administration of laminaria with EFM on the first day followed by oxytocin (Pitocin) infusion on the second day and evaluation of progress; on the third day, continued oxytocin (Pitocin) infusion with amniotomy

On vaginal exam, the clients cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishops score for this client is:

a. 6.

b. 9.

c. 10.

d. 12.

B- 9

Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents.

a.

Concurrent use of oxytocin and dinoprostone (Cervidil)

b.

Misoprostol (Cytotec) 25 mcg, followed in 4 hours by oxytocin induction in vaginal birth after cesarean section (VBAC) client

c.

Dinoprostone (Cervidil) 10 mg in place for 12 hours followed by oxytocin induction in 1 hour

d.

Maximum dose of dinoprostone (Prepidil) 2 mg/24 hr followed in 4 hours by oxytocin induction

C- Dinoprostone 10 mg in place for 12 hours followed by oxytocin induction in 1 hour

When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately:

a.

stop oxytocin infusion.

b.

administer O2 at 8 TO 10 L/min.

c.

reposition client to left side-lying position.

d.

increase the rate of the primary nonadditive infusion.

A. stop the oxytocin infusion

Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?

a.

Presence of newborn reflexes

b.

Symmetry of facial movements

c.

Caput and molding of the head

d.

Anterior and posterior fontanels

B- Symmetry of facial movements

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

a.

Anterior fontanel

b.

Coronal suture lines

c.

Posterior fontanel

d.

Biparietal diameter

C- Posterior fontanel

In which client situation could an amniotomy be safely performed?

a.

G1 P0, 38 weeks gestation, 20% effaced, closed cervix

b.

G2 P1, 40 weeks gestation, with fetus in a breech presentation

c.

G2 P0, 39 weeks gestation, 70% effaced, cervix dilated 2 cm

d.

G3 P2, 41 weeks gestation, early labor complicated with hydramnios

C- G2 P0, 39 weeks gestation, 70% effaced, cervix dilated 2 cm

When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurses best response would be to:

a.

stop the drip immediately.

b.

decrease the dose to 14 mU/min.

c.

reassess the patient at 5 minute intervals.

d.

reposition the patient to the left side-lying position.

B- Decrease the dose to 14 mU/min

Which breech presentation should the nurse recognize as being favorable for an external cephalic version?

a.

36-week gestation with low-lying placenta

b.

38-week gestation with one previous cesarean

c.

37-week gestation with fetal weight of 7 pounds

d.

40-week gestation with several uterine fibroids

C- 37-week gestation with fetal weight of 7 pounds

Following an external cephalic version, which assessment finding indicates a complication?

a.

Onset of irregular contractions

b.

Maternal blood pressure of 110/70 mm Hg

c.

Deceleration of FHR to 88 bpm

d.

Maternal pulse rate of 100 bpm

C- Deceleration of FHR to 88 bpm

In which of these situations should the nurse anticipate the use of forceps or vacuum extraction?

a.

Complete dilation for 2 hours at +2 station

b.

Complete dilation for 1 hour, transverse arrest at station +1

c.

Complete dilation for 3 hours, fetus at +3 station, onset of late deceleration

d.

Complete dilation for 1 hour, fetal descent from 0 station to + 1 in 1 hour

C- Complete dilation for 3 hours, fetus at +3 station, onset of late deceleration

Which assessment finding is indicative of a major complication 1 hour following a forceps birth?

a.

Uterine fundus displaced at U + 1

b.

Complaints of vaginal and uterine pain

c.

Peripads showing moderate lochia rubra

d.

Increase in pulse rate from 90 to 110 bpm

D- Increase in pulse rate from 90 to 110 bpm

A pregnant woman develops hypertension. The nurse monitors the clients blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with what complication?

a.

Abruptio placentae

b.

Cardiac abnormalities in the neonate

c.

Neonatal jaundice

d.

Reduced placental blood flow

D- Reduced placental blood flow

The pregnant client is admitted to the labor and birth unit for induction of labor. Which finding would allow the induction to continue as planned?

a.

Abruptio placentae

b.

Cephalopelvic disproportion

c.

Ripening of the cervix

d.

Umbilical cord prolapse

C- Ripening of the cervix

The pregnant client expresses a desire to schedule birth during the babys fathers furlough from the Army. The nurse explains that prior to induction of labor, it is essential to determine which condition?

a.

Dilated cervix

b.

Fetal lung maturity

c.

Rupture of membranes

d.

Uterine hypertonia

B- Fetal lung maturity

The nurse monitors the client in labor for signs and symptoms of water intoxication. Which finding indicates that this may be occurring?

a.

Hypotension

b.

Rales and wheezes

c.

Slow shallow breathing

d.

Tachycardia

B- Rales and wheezes

After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurses concern about this risk?

a.

Hypovolemia

b.

Iron deficiency anemia

c.

Prolonged use of oxytocin

d.

Uteroplacental insufficiency

C- Prolonged use of oxytocin

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99 F [37.2 C]. What is the priority nursing action for this patient?

a.

Fetal acoustic stimulation

b.

Assess temperature every 2 hours

c.

Change absorption pads under her hips every 2 hours

d.

Review white blood cell count (WBC) drawn at admission

B- Assess temperature every 2 hours

The labor nurse is providing care for a patient admitted for induction of labor at 38 weeks gestation. The patients Bishop score is 5, and an infusion of oxytocin (Pitocin) is initiated with orders that read as follows: mix 30 units of Pitocin in 500 mL of NS, increase the rate of infusion by 2 mL/hr every 15 to 60 minutes until a pattern of three contractions in 10 minutes is established. What is the priority nursing action for this patient?

a.

Increase the infusion of Pitocin every 30 to 60 minutes.

b.

Assess for changes in the patients cervix every 2 hours.

c.

Obtain a reactive nonstress test prior to starting the infusion.

d.

Determine the fetal heart rate baseline for 30 minutes prior to starting the infusion.

A- Increase the infusion of Pitocin every 30 to 60 minutes

A patient who is a 2-1-0-0-1 at 34 weeks gestation is interested in a vaginal birth after cesarean section (VBAC) and asks the nurse about this possibility. Which reason for her primary cesarean section would indicate to the nurse that the patient should be discouraged from pursuing this option?

a.

Transverse lie

b.

Prolapsed cord

c.

Placenta previa

d.

Cephalopelvic disproportion (CPD)

D- Cephalopelvic disproportion

Which adverse effects can be seen in response to administration of oxytocin (Pitocin) for induction of labor? (Select all that apply.) THREE answers

a.

Maternal hyponatremia

b.

Uterine tachysystole

c.

Maternal hypotension

d.

Reassuring fetal heart pattern

e.

Decreased variability on fetal tracing

A- Maternal hyponatremia

B- Uterine tachysystole

C- Maternal hypotension

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.) FOUR answers

a.

Fetal death

b.

Post-term pregnancy

c.

Rupture of membranes at or near term

d.

Convenience of the client or her health care provider

e.

Chorioamnionitis (inflammation of the amniotic sac)

A- Fetal Death

B- Post-term pregnancy

C- Rupture of membranes at or near term

E- Chorioamnionitis

The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.)

a.

Assist the client to the bathroom.

b.

Position the client in a high Fowler position.

c.

Assess the uterus for excessive contractions.

d.

Monitor the fetal heart rate for at least 30 minutes.

C- Assess the uterus for excessive contractions

A client is scheduled for an external cephalic version (ECV). Which should the nurse prepare to implement? (Select all that apply.) THREE answers

a.

Initiation of an intravenous (IV) line

b.

Obtaining a baseline fetal monitoring pattern

c.

Administration of an oxytocin (Pitocin) infusion as prescribed

d.

Planning to observe the client and fetus for 1 hour after the procedure

e.

Administration of an Rh immunoglobulin after the procedure to Rh-positive client

A- Initiation of intravenous (IV) line

B- Obtaining a baseline fetal monitoring pattern

D- Planning to observe the client and fetus for 1 hour after procedure

A client asks the nurse, What can I do to avoid an episiotomy during birth? Which responses should the nurse give? (Select all that apply). THREE answers

a.

Using the lithotomy position during pushing may be beneficial.

b.

Using prolonged breath-holding when pushing may help stretch the tissue.

c.

Beginning at 36 weeks, a daily 10-minute perineal massage may help stretch the tissue.

d.

Using an open glottis technique when pushing can promote gradual perineal stretching.

e.

Delaying pushing until the urge is felt can gradually distend the soft tissues of the pelvic floor.

C

D

E