Olds Maternal-Newborn nursing ch 23: Childbirth @ Risk: Pre-labor Onset Complications

The nurse has admitted a woman with cervical insufficiency. The nurse is aware that causes of this condition include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Congenital factors

2. Intercourse during pregnancy

3. Infection

4. Increased uterine volume

5. Past cervical surgeries

1, 3, 4, 5

(Explanation: 1. Congenitally incompetent cervix may be found in women exposed to diethylstilbestrol (DES) or those with a bicornuate uterus.

3. Infection or trauma can cause acquired cervical incompetence.

4. Cervical insufficiency can occur in multiple-gestation pregnancies.

5. Previous elective abortion or cervical manipulation can lead to cervical insufficiency.)

The nurse is admitting a client for a cerclage procedure. The client asks for information about the procedure. What is the nurse's most accurate response?

1. "A stitch is placed in the cervix to prevent a spontaneous abortion or premature birth."

2. "The procedure is done during the third trimester."

3. "Cerclage is always placed after the cervix has dilated and effaced."

4. "An uncomplicated elective cerclage may is done on inpatient basis."

1

(Explanation: 1. This is the correct description of cerclage.)

A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for?

1. Gestational diabetes

2. Placenta previa

3. Abruptio placentae

4. Placenta accreta

3

(Explanation: 3. Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age, cocaine use, chorioamnionitis, and hypertension.)

The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching?

1. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured."

2. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again."

3. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy."

4. "If I have aminocentesis, I might rupture the membranes again."

3

(Explanation: 3. There is no evidence that bed rest in a subsequent pregnancy decreases the risk for PPROM.)

A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect?

1. Blood pressure

2. Temperature

3. Pulse

4. Respiration

2

(Explanation: 2. Rupture of membranes places the mother at risk for infection. The temperature is the primary and often the first indication of a problem.)

The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor?

1. Cervical effacement of 30% or more

2. Cervical change of 0.5 cm per hour

3. 2 contractions in 30 minutes

4. 8 contractions in 1 hour

4

(Explanation: 4. 8 contractions in a 60 minute period does define a diagnosis of preterm labor.)

During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be?

1. To help the fetal head descend faster

2. To use gravity and manipulation to relieve compression on the cord

3. To facilitate dilation of the cervix with prostaglandin gel

4. To prevent head compression

2

(Explanation: 2. The top priority is to relieve compression on the umbilical cord to allow blood flow to reach the fetus. It is because some obstetric maneuvers to relieve cord compression are complicated that cesarean birth is sometimes necessary.)

A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be?

1. Perform a vaginal exam

2. Notify the physician

3. Place the client in a left lateral position

4. Administer oxygen at 2 L per nasal cannula

1

(Explanation: 1. Prolapsed umbilical cord can occur when the membranes rupture. The fetus is more likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm.)

The nurse has received end-of-shift reports in the high-risk maternity unit. Which client should the nurse see first?

1. The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement

2. The client at 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations

3. The client at 35 weeks' gestation with grade I abruptio placentae in labor who has a strong urge to push

4. The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously

1

(Explanation: 1. Assessment of the woman with placenta previa must be ongoing to prevent or treat complications that are potentially lethal to the mother and fetus. Painless, bright red vaginal bleeding is the best diagnostic sign of placenta previa. This client is the highest priority.)

The nurse is presenting a class on preterm labor, its causes, and treatments to a group of newly pregnant couples. Which statements regarding preterm labor are true?

Note: Credit will be given only of all correct choices and no incorrect choices are selected.

Select all that apply.

1. Antepartum hemorrhage can cause preterm labor.

2. Trauma can cause preterm labor.

3. Infection can cause preterm labor.

4. Magnesium sulfate is a drug used to stop contractions.

5. Sedatives and narcotics may be given to stop labor.

1, 2, 3, 4

(Explanation: 1. Hemorrhage from placenta previa or abruption can cause preterm labor.

2. Trauma to the abdomen or uterus can cause preterm labor.

3. Infections such as urinary tract infections can cause preterm labor.

4. Magnesium sulfate acts as a CNS depressant by decreasing the quantity of acetylcholine released by motor nerve impulses and thereby blocking neuromuscular transmission.)

A client in her second trimester is complaining of spotting. Causes for spotting in the second trimester are diagnosed primarily through the use of which of the following?

1. A nonstress test

2. A vibroacoustic stimulation test

3. An ultrasound

4. A contraction stress test

3

(Explanation: 3. Indirect diagnosis is made by localizing the placenta via tests that require no vaginal examination. The most commonly employed diagnostic test is the transabdominal ultrasound scan.)

A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound. What should be included in the nursing plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. No vaginal exams

2. Encouraging activity

3. No intravenous access until labor begins

4. Evaluating fetal heart rate with an external monitor

5. Monitoring blood loss, pain, and uterine contractility

1, 4, 5

(Explanation: 1. Expectant management of placenta previa is made by localizing the placenta via tests that require no vaginal examination.

4. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes evaluating FHR with an external monitor.

5. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes monitoring blood loss, pain, and uterine contractility.)

The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Diabetes mellitus

2. Abruptio placentae

3. Fetal demise

4. Multiparity

5. Preterm labor

2, 3

(Explanation: 2. As a result of the damage to the uterine wall and the retroplacental clotting with covert abruption, large amounts of thromboplastin are released into the maternal blood supply, which in turn triggers the development of disseminated intravascular coagulation (DIC) and the resultant hypofibrinogenemia.

3. Perinatal mortality associated with abruptio placentae is approximately 25%. If fetal hypoxia progresses unchecked, irreversible brain damage or fetal demise may result.)

The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes which of the following?

1. Limiting vaginal exams to only one per 24-hour period.

2. Evaluating the fetal heart rate with an internal monitor.

3. Monitoring for blood loss, pain, and uterine contractibility.

4. Assessing blood pressure every 2 hours.

3

(Explanation: 3. Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety.)

A client is admitted to the labor and delivery unit in active labor. What nursing diagnoses might apply to the client with suspected abruptio placentae?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Fluid Volume, Deficient, Risk for, related to hypovolemia secondary to excessive blood loss

2. Tissue Perfusion: Peripheral, Ineffective, related to blood loss secondary to uterine atony following birth

3. Anxiety related to concern for own personal status and the baby's safety

4. Knowledge, Deficient related to lack of information about inherited genetic defects

5. Alteration in Respiratory Function related to blood loss

1, 2, 3

(Explanation: 1. Maternal and perinatal fetal mortality are concerns due to hypoxia.

2. Maternal and perinatal fetal mortality are concerns due to blood loss.

3. This mother would be anxious for herself and her baby.)

What is the most significant cause of neonatal morbidity and mortality?

1. Amenorrhea

2. Posttraumatic stress disorder

3. Prematurity

4. Endometriosis

3

(Explanation: 3. The most significant cause of neonatal morbidity and mortality is prematurity and its associated complications such as respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage.)

What is the most significant maternal risk factor for preterm birth?

1. Previous preterm birth

2. Smoking

3. Stress

4. Substance abuse

1

(Explanation: 1. The most significant maternal risk factor for preterm birth is a previous preterm birth.)

A pregnant client is admitted to the emergency department with bleeding. The nurse realizes that the client might have placenta previa. Which signs would be suggestive of placenta previa?

1. Bright red vaginal bleeding

2. Sudden onset of vaginal bleeding

3. Firm and hard uterus

4. Change in the size of abdomen

1

(Explanation: 1. As the lower uterine segment contracts and dilates, the placental villi are torn from the uterine wall, causing bright red bleeding.)

The nurse educator is describing the different kinds of abruptio placentae to a group of students, explaining that in a complete abruptio placentae, which of the following occurs?

1. Separation begins at the periphery of the placenta.

2. The placenta separates centrally and blood is trapped between the placenta and the uterine wall.

3. There is massive vaginal bleeding in the presence of almost total separation.

4. Blood passes between the fetal membranes and the uterine wall, and escapes vaginally.

3

(Explanation: 3. There is massive vaginal bleeding in the presence of almost total separation describes a complete separation of the placenta.)

The labor nurse is caring for a client at 38 weeks' gestation who has been diagnosed with symptomatic placenta previa. Which physician order should the nurse question?

1. Begin oxytocin drip rate at 0.5 milliunits/min.

2. Assess fetal heart rate every 10 minutes.

3. Weigh all vaginal pads.

4. Assess hematocrit and hemoglobin.

1

(Explanation: 1. This order should be questioned, as this client is not a good candidate for labor induction.)

The nurse is presenting a class for nursing students on multiple-gestation pregnancy. Which statements about multiple-gestation pregnancies are accurate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Hypertension is a major maternal complication.

2. Gestational diabetes occurs more often.

3. Maternal anemia occurs.

4. Pulmonary embolism is 12 times more likely to develop during pregnancy with multiple gestations.

5. Multiple gestations are more likely to acquire HELLP.

1, 2, 3, 5

(Explanation: 1. Hypertension is a complication in multiple-gestation pregnancies.

2. Gestational diabetes occurs more often in multiple gestations.

3. Maternal anemia occurs because of demands of the multiple gestations.

5. Multiple gestations are more likely to acquire HELLP (hemolytic anemia, elevated liver enzymes, and low platelet count) syndrome, a complication resulting from eclampsia or preeclampsia.)

What can be determined based on ultrasound visualization or the lack of visualization of an intertwin membrane?

1. Toxicity

2. Amnionicity

3. Variability

4. Prematurity

2

(Explanation: 2. Evidence supports the use of ultrasound for accurately determining chorionicity and amnionicity in multiple pregnancies. Determination of amnionicity is based on ultrasound visualization or the lack of visualization of an intertwin membrane.)

What fetal factors require a cesarean birth?

1. Severe intrauterine growth restriction (IUGR)

2. Fetal anomalies

3. Unfavorable fetal position or presentation

4. Preterm birth

5. Lack of maternal attachment

1, 2, 3, 4

(Explanation: 1. Fetal factors such as severe intrauterine growth restriction (IUGR), preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorable fetal position or presentation require cesarean birth.

2. Fetal factors such as severe intrauterine growth restriction (IUGR), preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorable fetal position or presentation require cesarean birth.

3. Fetal factors such as severe intrauterine growth restriction (IUGR), preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorable fetal position or presentation require cesarean birth.

4. Fetal factors such as severe intrauterine growth restriction (IUGR), preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorable fetal position or presentation require cesarean birth.)

The home health nurse is admitting a client at 18 weeks who is pregnant with twins. Which nursing action is most important?

1. Teach the client about foods that are good sources of protein.

2. Assess the client's blood pressure in her upper right arm.

3. Determine whether the pregnancy is the result of infertility treatment.

4. Collect a cervicovaginal fetal fibronectin (fFN) specimen.

1

(Explanation: 1. A daily intake of 4000 kcal (minimum) and 135 g protein is recommended for a woman with normal-weight twins.)

The client is carrying monochorionic-monoamniotic twins. The nurse teaches the client what this is, and the implications of this finding. The nurse knows that teaching is successful when the client states which of the following?

1. "My babies came from two eggs."

2. "About two thirds of twins have this amniotic sac formation."

3. "My use of a fertility drug led to this issue."

4. "My babies have a lower chance of surviving to term than fraternal twins do."

4

(Explanation: 4. Monochorionic-monoamniotic twins are both in one amniotic sac. There is an increased risk of umbilical cords becoming tangled or knotted and a higher incidence of fetal demise.)

When counseling a newly pregnant client at 8 weeks' gestation of twins, the nurse teaches the woman about the need for increased caloric intake. What would the nurse tell the woman that the minimum recommended intake should be?

1. 2500 kcal and 120 grams protein

2. 3000 kcal and 150 grams protein

3. 4000 kcal and 135 grams protein

4. 5000 kcal and 190 grams protein

3

(Explanation: 3. 4000 kcal and 135 grams protein is the recommended caloric and protein intake in a twin-gestation pregnancy.)

Intervention to reduce preterm birth can be divided into primary prevention and secondary prevention. What does secondary prevention include?

1. Diagnosis and treatment of infections

2. Cervical cerclage

3. Progesterone administration

4. Antibiotic treatment and tocolysis

4

(Explanation: 4. Secondary prevention strategies are antibiotic treatment and tocolysis.)

The nurse is caring for a client with hydramnios. What will the nurse watch for?

1. Possible intrauterine growth restriction

2. Newborn congenital anomalies

3. Newborn postmaturity and renal malformations

4. Fetal adhesions

2

(Explanation: 2. Newborn congenital anomalies occur with hydramnios)

Slowly removing some amniotic fluid is a treatment for hydramnios. What consequence can occur with the withdrawal of fluid?

1. Preterm labor

2. Prolapsed cord

3. Preeclampsia

4. Placenta previa

2

(Explanation: 2. A needle or a fetal scalp electrode is used to make a small puncture in the amniotic sac. There is a risk that the force of the fluid could make a larger hole in the amniotic sac, thus increasing the risk of a prolapsed cord.)

The nurse is admitting a client who was diagnosed with hydramnios. The client asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Rh sensitization

2. Postmaturity syndrome

3. Renal malformation or dysfunction

4. Maternal diabetes

5. Large-for-gestational-age infants

1, 4

(Explanation: 1. Hydramnios is associated with Rh sensitization.

4. Hydramnios is associated with maternal diabetes.)

The nurse is admitting a client with possible hydramnios. When is hydramnios most likely suspected?

1. Hydramnios is most likely suspected when there is less amniotic fluid than normal for gestation.

2. Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation.

3. Hydramnios is most likely suspected when the woman has a twin gestation.

4. Hydramnios is most likely suspected when the quadruple screen comes back positive.

2

(Explanation: 2. Hydramnios should be suspected when the fundal height increases out of proportion to the gestational age.)

If oligohydramnios occurs in the first part of pregnancy, the nurse knows that there is a danger of which of the following?

1. Major congenital anomalies

2. Fetal adhesions

3. Maternal diabetes

4. Rh sensitization

2

(Explanation: 2. If oligohydramnios occurs in the first part of pregnancy, there is a danger of fetal adhesions (one part of the fetus may adhere to another part).)

When caring for a laboring client with oligohydramnios, what should the nurse be aware of?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Increased risk of cord compression

2. Decreased variability

3. Labor progress is often more rapid than average

4. Presence of periodic decelerations

5. During gestation, fetal skin and skeletal abnormalities can occur

1, 2, 4, 5

(Explanation: 1. During the labor and birth, the lessened amounts of fluid reduce the cushioning effect for the umbilical cord, and cord compression is more likely to occur.

2. The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations).

4. The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations).

5. During the gestational period, fetal skin and skeletal abnormalities may occur because fetal movement is impaired as a result of inadequate amniotic fluid volume.)

The nurse knows that a baby born to a mother who had oligohydramnios could show signs of which of the following?

1. Respiratory difficulty

2. Hypertension

3. Heart murmur

4. Decreased temperature

1

(Explanation: 1. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop.)

The client at 38 weeks' gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching about the condition has been effective?

1. "My gestational diabetes might have caused this problem to develop."

2. "When I go into labor, I should come to the hospital right away."

3. "This problem was diagnosed with blood and urine tests."

4. "Women with this condition usually do not have a cesarean birth."

2

(Explanation: 2. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid. The client with oligohydramnios should come to the hospital in early labor.)

The nurse is planning care for a client with hydramnios. For which interventions might the nurse need to prepare the client?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Artificial rupture of the membranes

2. Amnioinfusion

3. Amniocentesis

4. Administration of prostaglandin synthesis inhibitor

5. Administration of indomethacin

1, 3, 4, 5

(Explanation: 1. Artificial rupture may be performed to remove the excessive fluid.

3. Amniocentesis may be performed to remove some excess fluid.

4. A prostaglandin synthesis inhibitor is used to treat hydramnios.

5. Indomethacin can decrease amniotic fluid by decreasing fetal urine output.)