Olds Maternal-Newborn nursing ch 24: Childbirth @ Risk: Labor-Related

What would be a normal cervical dilatation rate in a first-time mother ("primip")?

1. 1.5 cm per hour

2. Less than 1 cm cervical dilatation per hour

3. 1 cm per hour

4. Less than 0.5 cm per hour

1

(Explanation: 1. Dilatation in a "multip" is about 1.5 cm per hour.)

Dystocia encompasses many problems in labor. What is the most common?

1. Meconium-stained amniotic fluid

2. Dysfunctional uterine contractions

3. Cessation of contractions

4. Changes in the fetal heart rate

2

(Explanation: 2. The most common problem is dysfunctional (or uncoordinated) uterine contractions that result in a prolongation of labor.)

Risk factors for tachysystole 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. Cocaine use

2. Placental abruption

3. Low-dose oxytocin titration regimens

4. Uterine rupture

5. Smoking

1, 2, 4

(Explanation: 1. Cocaine use is a risk factor for tachysystole.

2. Placental abruption is a risk factor for tachysystole.

4. Uterine rupture is a risk factor for tachysystole.)

A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for?

1. Oxytocin induction of labor

2. Amnioinfusion

3. Increased intravenous infusion

4. Cesarean section

1

(Explanation: 1. Oxytocin is the drug of choice for labor augmentation or labor induction and may be administered as needed for hypotonic labor patterns.)

Nonreassuring fetal status often occurs with a tachysystole contraction pattern. Intrauterine resuscitation measures may become warranted and can include which of the following measures?

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

Select all that apply.

1. Position the woman on her right side.

2. Apply oxygen via face mask.

3. Call for anesthesia provider for support.

4. Increase intravenous fluids by at least 700 mL bolus.

5. Call the physician/CNM to the bedside.

2, 3, 4

(Explanation: 2. The nurse would apply oxygen via face mask.

3. The nurse would call for anesthesia provider for support.

4. The nurse would increase intravenous fluids by at least 500 mL bolus.)

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern?

1. 34-year-old woman at 39 weeks' gestation with a large-for-gestational-age (LGA) fetus

2. 22-year-old woman at 23 weeks' gestation with ruptured membranes

3. 30-year-old woman at 41 weeks' gestation and estimated fetal weight 7 pounds 8 ounces

4. 43-year-old woman at 37 weeks' gestation with hypertension

1

(Explanation: 1. A risk factor for hypotonic uterine contraction patterns includes a large-for-gestational-age (LGA) fetus.)

Two hours ago, a client at 39 weeks' gestation was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds' duration and intensity of 40 mmHg. What would the priority intervention be?

1. Begin oxytocin after assessing for CPD.

2. Give terbutaline to stop the preterm labor.

3. Start oxygen at 8 L/min.

4. Have the anesthesiologist give the client an epidural.

1

(Explanation: 1. The client is having hypertonic contractions. Cephalopelvic disproportion (CPD) must be excluded. If CPD exists, oxytocin (Pitocin) augmentation should not be used. Oxytocin is the drug of choice for labor augmentation or labor induction.)

What are the primary complications of placenta accrete?

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

Select all that apply.

1. Maternal hemorrhage

2. Insomnia

3. Failure of the placenta to separate following birth of the infant

4. Autonomic dysreflexia

5. Shoulder dystocia

1, 3

(Explanation: 1. The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant.

3. The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant.)

) Risk factors for labor dystocia 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. Tall maternal height

2. Labor induction

3. Small-for-gestational-age (SGA) fetus

4. Malpresentation

5. Prolonged latent phase

2, 4, 5

(Explanation: 2. Labor induction is a risk factor of dystocia.

4. Malpresentation is a risk factor of dystocia.

5. Prolonged latent phase is a risk factor of dystocia.)

In succenturiate placenta, one or more accessory lobes of fetal villi have developed on the placenta, with vascular connections of fetal origin. What is the gravest maternal danger?

1. Cord prolapse

2. Postpartum hemorrhage

3. Paroxysmal hypertension

4. Brachial plexus injury

2

(Explanation: 2. The gravest maternal danger is postpartum hemorrhage if this minor lobe is severed from the placenta and remains in the uterus.)

The nurse knows that the maternal risks associated with postterm pregnancy 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. Polyhydramnios

2. Maternal hemorrhage

3. Maternal anxiety

4. Forceps-assisted delivery

5. Perineal damage

2, 3, 4, 5

(Explanation: 2. Maternal symptoms and complications in postterm pregnancy may include maternal hemorrhage.

3. Maternal symptoms and complications in postterm pregnancy may include maternal anxiety.

4. Maternal symptoms and complications in postterm pregnancy may include an operative vaginal birth with forceps or vacuum extractor.

5. Maternal symptoms and complications in postterm pregnancy may include perineal trauma and damage.)

The client is at 42 weeks' gestation. Which order should the nurse question?

1. Obtain biophysical profile today.

2. Begin nonstress test now.

3. Schedule labor induction for tomorrow.

4. Have the client return to the clinic in 1 week.

4

(Explanation: 4. Many practitioners use twice-weekly testing providing the amniotic fluid level is normal. One week is too long a period between assessments.)

During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents?

1. The infant will need to be observed for meconium aspiration.

2. Facial edema and head molding will subside in a few days.

3. The infant will be given prophylactic antibiotics.

4. Breastfeeding will need to be delayed for a day or two.

2

(Explanation: 2. Any facial edema and head molding that result from the use of forceps at birth will subside in a few days.)

The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important?

1. Artificially rupture membranes.

2. Apply internal fetal scalp electrode.

3. Monitor maternal blood pressure every 15 minutes.

4. Alert surgical team of urgent cesarean.

4

(Explanation: 4. This is the highest priority because vaginal birth is impossible with a transverse lie. Labor should not be allowed to continue, and a cesarean birth is done quickly.)

The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which of the following?

1. Shorter than average during the latent phase

2. Prolonged as regards the overall length of labor

3. Rapid during transition

4. Precipitous

2

(Explanation: 2. Occiput posterior (OP) position of the fetus is the most common fetal malposition and occurs when the head remains in the direct OP position throughout labor. This can prolong the overall length of labor.)

Maternal risks of occiput posterior (OP) malposition 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. Blood loss greater than 1000 mL

2. Postpartum infection

3. Anal sphincter injury

4. Higher rates of vaginal birth

5. Instrument delivery

2, 3, 5

(Explanation: 2. Postpartum infection is a maternal risk of OP.

3. Anal sphincter injury is a maternal risk of OP.

5. Instrument delivery is a maternal risk of OP.)

Which of the following potential problems would the nurse consider when planning care for a client with a persistent occiput posterior position of the fetus?

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

Select all that apply.

1. Increased fetal mortality

2. Severe perineal lacerations

3. Ceasing of labor progress

4. Fetus born in posterior position

5. Intense back pain during labor

2, 3, 4, 5

(Explanation: 2. The woman can have third- or fourth-degree perineal laceration or extension of a midline episiotomy.

3. Sometimes labor progress ceases if the fetus fails to rotate to an occiput anterior position.

4. Occiput posterior positions are associated with a higher incidence of vacuum-assisted births.

5. The woman usually experiences intense back pain in the small of her back throughout labor.)

If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist?

1. Call a second physician to assist.

2. Prepare for an immediate cesarean delivery.

3. Assist the woman into McRoberts maneuver.

4. Utilize fundal pressure to push the fetus out.

3

(Explanation: 3. The McRoberts maneuver is thought to change the maternal pelvic angle and therefore reduce the force needed to extract the shoulders, thereby decreasing the incidence of brachial plexus stretching and clavicular fracture.)

The client has undergone an ultrasound, which estimated fetal weight at 4500 g (9 pounds 14 ounces). Which statement indicates that additional teaching is needed?

1. "Because my baby is big, I am at risk for excessive bleeding after delivery."

2. "Because my baby is big, his blood sugars could be high after he is born."

3. "Because my baby is big, my perineum could experience trauma during the birth."

4. "Because my baby is big, his shoulders could get stuck and a collarbone broken."

2

(Explanation: 2. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.)

The client vaginally delivers an infant that weighs 4750 g. Moderate shoulder dystocia occurred during the birth. During the initial assessment of this infant, what should the nurse look for?

1. Bell's palsy

2. Bradycardia

3. Erb palsy

4. Petechiae

3

(Explanation: 3. Macrosomic newborns should be inspected for cephalhematoma, Erb palsy, and fractured clavicles.)

The nurse caring for a client in labor anticipates fetal macrosomia and shoulder dystocia. Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications?

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

Select all that apply.

1. Brachial plexus injury

2. Fractured clavicle

3. Asphyxia

4. Neurological damage

5. Puerperal infection

1, 2, 3, 4

(Explanation: 1. Brachial plexus injury occurs due to improper or excessive traction applied to the fetal head.

2. Complications in macrosomia include fractured clavicles.

3. Complications in macrosomia include asphyxia of the fetus.

4. Neurological damage is a complication of macrosomia.)

True postterm pregnancies are frequently associated with placental changes that cause a decrease in the uterine-placental-fetal circulation. Complications related to alternations in placenta functioning 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. Increased fetal oxygenation

2. Increased placental blood supply

3. Reduced nutritional supply

4. Macrosomia

5. Risk of shoulder dystocia

3, 4, 5

(Explanation: 3. Reduced nutritional supply is a complication related to alternations in placenta functioning.

4. Macrosomia is a complication related to alternations in placenta functioning.

5. Risk of shoulder dystocia is a complication)

The nurse examines the client's placenta and finds that the umbilical cord is inserted at the placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what?

1. Placenta accreta

2. Circumvallate placenta

3. Succenturiate placenta

4. Battledore placenta

4

(Explanation: 4. In battledore placenta, the umbilical cord is inserted at or near the placental margin.)

A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse 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. A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord. The nurse would assess for prolapsed cord via vaginal examination.)

The nurse is caring for a client in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?

1. Assess the odor of the amniotic fluid.

2. Perform Leopold maneuvers.

3. Obtain an order for pain medication.

4. Complete a sterile vaginal exam.

4

(Explanation: 4. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. The nurse would assess for prolapsed cord via vaginal examination.)

During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for 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. Intravenous access

2. Cesarean delivery

3. Immediate vaginal delivery

4. McRoberts maneuver

5. A crash cart

1, 2, 5

(Explanation: 1. When an amniotic fluid embolism is suspected, intravenous access is obtained as quickly as possible.

2. Shortness of breath, cyanosis, and hypoxia are symptoms of an amniotic fluid embolus, which necessitates immediate cesarean delivery.

5. The chances of a code are high, so the crash cart needs to be available.)

On assessment, a labor client is noted to have cardiovascular and respiratory collapse and is unresponsive. What should the nurse suspect?

1. An amniotic fluid embolus

2. Placental abruption

3. Placenta accreta

4. Retained placenta

1

(Explanation: 1. Cardiovascular and respiratory collapse are symptoms of an amniotic fluid embolus and cor pulmonale.)

Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture?

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

Select all that apply.

1. Age 15, in active labor

2. Age 22, with eclampsia

3. Age 25, last delivery by cesarean section

4. Age 32, first baby died during labor

5. Age 27, last delivery 11 months ago

3, 5

(Explanation: 3. A woman who has had a previous cesarean section is at risk for uterine rupture.

5. A woman who does not have at least 18 months between deliveries is at greater risk for uterine rupture.)

The nurse is caring for a client who could be at risk for uterine rupture. The nurse is monitoring the fetus closely for 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. Late decelerations

2. Bradycardia

3. Loss of ability to determine fetal station

4. Tachycardia

5. Early decelerations

1, 2, 3

(Explanation: 1. Late decelerations could be seen with uterine rupture.

2. Bradycardia is seen if there is uterine rupture.

3. The uterus is not holding the fetus in place anymore if the uterus ruptures.)

A 26-year-old client is having her initial prenatal appointment. The client reports to the nurse that she suffered a pelvic fracture in a car accident 3 years ago. The client asks whether her pelvic fracture might affect her ability to have a vaginal delivery. What response by the nurse is best?

1. "It depends on how your pelvis healed."

2. "You will need to have a cesarean birth."

3. "Please talk to your doctor about that."

4. "You will be able to delivery vaginally."

1

(Explanation: 1. Women with a history of pelvic fractures may also be at risk for cephalopelvic disproportion (CPD).)

) In caring for a client with a uterine rupture, the nurse determines which nursing diagnoses to be appropriate?

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

Select all that apply.

1. Gas Exchange, Impaired

2. Fear related to unknown outcome

3. Coping, Ineffective

4. Mobility: Physical, Impaired

5. Anxiety

1, 2, 3, 5

(Explanation: 1. Gas Exchange, Impaired diagnosis could apply to both mother and fetus.

2. The client would experience fear related to an unknown outcome.

3. Ineffective coping would be due to emergent situation secondary to uterine rupture.

5. There will be anxiety related to emergency procedures and unknown fetal outcome.)

A fetal weight is estimated at 4490 grams in a client at 38 weeks' gestation. Counseling should occur before labor regarding which of the following?

1. Mother's undiagnosed diabetes

2. Likelihood of a cesarean delivery

3. Effectiveness of epidural anesthesia with a large fetus

4. Need for early delivery

2

(Explanation: 2. The likelihood of a cesarean delivery with a fetus over 4000 grams is high. This should be discussed with the client before labor.)

A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced. The fetal presenting part is not engaged. The nurse would suspect which of the following?

1. Breech malpresentation

2. Fetal demise

3. Cephalopelvic disproportion (CPD)

4. Abruptio placentae

3

(Explanation: 3. Cephalopelvic disproportion (CPD) prevents the presenting part from becoming engaged.)

What is one of the most common initial signs of nonreassuring fetal status?

1. Meconium-stained amniotic fluid

2. Cyanosis

3. Dehydration

4. Arrest of descent

1

(Explanation: 1. The most common initial signs of nonreassuring fetal status are meconium-stained amniotic fluid and changes in the fetal heart rate (FHR).)

The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do?

1. Start an IV of lactated Ringer's.

2. Apply anti-embolism stockings.

3. Bottle-feed the infant.

4. Send the placenta to pathology.

1

(Explanation: 1. In women who do not have an epidural in place, intravenous sedation may be required because of the discomfort caused by the procedure. An IV is necessary.)

The client delivered 30 minutes ago. Her blood pressure and pulse are stable. Vaginal bleeding is scant. The nurse should prepare for which procedure?

1. Abdominal hysterectomy

2. Manual removal of the placenta

3. Repair of perineal lacerations

4. Foley catheterization

2

(Explanation: 2. Retention of the placenta beyond 30 minutes after birth is termed retained placenta. Manual removal of the placenta is then performed.)

Lacerations of the cervix or vagina may be present when bright red vaginal bleeding persists in the presence of a well-contracted uterus. The incidence of lacerations is higher among which of the following childbearing women?

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

Select all that apply.

1. Over the age of 35

2. Have not had epidural block

3. Have had an episiotomy

4. Have had a forceps-assisted or vacuum-assisted birth

5. Nulliparous

3, 4

(Explanation: 3. The incidence of lacerations is higher among childbearing women who undergo an episiotomy.

4. The incidence of lacerations is higher among childbearing women who undergo forceps-assisted or vacuum-assisted birth.)

After delivery, it is determined that there is a placenta accreta. Which intervention should the nurse anticipate?

1. 2 L oxygen by mask

2. Intravenous antibiotics

3. Intravenous oxytocin

4. Hysterectomy

4

(Explanation: 4. The primary complication of placenta accreta is maternal hemorrhage and failure of the placenta to separate following birth of the infant. An abdominal hysterectomy may be the necessary treatment, depending on the amount and depth of involvement.)

What is required for any women receiving oxytocin (Pitocin)?

1. CPR

2. Continuous electronic fetal monitoring

3. Administering oxygen by mask

4. Nonstress test

2

(Explanation: 2. Continuous electronic fetal monitoring (EFM) is required for any women receiving oxytocin (Pitocin).)

The client has delivered a 4200 g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best?

1. "The episiotomy extended and tore through your rectal mucosa."

2. "The episiotomy extended and tore up near your vaginal mucous membrane."

3. "The episiotomy extended and tore into the muscle layer."

4. "The episiotomy extended and tore through your anal sphincter."

4

(Explanation: 4. A third degree laceration includes the anal sphincter.)