Chapter 20 Childbirth at Risk: Pre-Labor and Intrapartum Complications

1) 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 bleeding in the third trimester of my next pregnancy, I might rupture membranes again."

Answer: 3

3. There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM.

2) A clinical nurse coordinator is teaching a class of nursing students about surgical and postoperative care of the woman who undergoes cerclage. Which nursing student's statement indicates the need for further clarification of the teaching?

1. "Sometimes cerclage can be performed on an outpatient basis."

2. "If cerclage is performed emergently, the woman will usually be hospitalized for at least 5 days."

3. "If the woman's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed."

4. "After 37 weeks' gestation, the woman's cerclage may be cut in order to allow for vaginal delivery."

Answer: 3

3. Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.

3) A 26-year-old woman who is pregnant with her first child is admitted to the obstetrics unit with a diagnosis of cervical insufficiency. Based upon the client's diagnosis, how is she most likely to describe her symptoms?

1. "I've been having contractions every four hours."

2. "My cervical pain has gotten much worse over the past two days."

3. "I'm not having any pain, but my contractions are getting stronger."

4. "I'm not having any pain and I don't feel any contractions."

Answer: 4

4. Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.

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

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

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

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

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

Answer: 1

Explanation: 1. Bleeding with a placenta previa is a complication that can be life-threatening to both the mother and baby. This client is the highest priority.

5) The nurse is planning an in-service educational program to talk about disseminating intravascular coagulation (DIC). The nurse should identify which of the following as risk factors for developing DIC? Select all that apply.

1. Diabetes mellitus

2. Abruptio placentae

3. Prolonged retention of a fetus after demise

4. Multiparity

5. Preterm labor

Answer: 2, 3

2. Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.

3. Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.

6) The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes:

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.

Answer: 3

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

7) A multigravida client is admitted to labor and delivery in active labor. Nursing diagnoses that might apply to the client with suspected abruptio placentae include (select all that apply):

1. Fluid volume, risk for deficit related to hypovolemia.

2. Tissue perfusion, risk for altered related to blood loss.

3. Anxiety related to concern for own safety.

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

Answer: 1, 2, 3

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

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

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

8) The charge nurse is reviewing the physician's notes describing the diagnosis of abruptio placentae in a client who is currently admitted. The physician describes the woman's placental separation as being "central." Based upon this description, what can the nurse infer about the woman's condition?

1. Blood is trapped between the woman's placenta and the uterine wall, and she may have concealed bleeding.

2. The total separation of the woman's placenta from the uterine wall will lead to massive hemorrhage.

3. Blood is passing between the fetal membranes and the woman's uterine wall, which will lead to some vaginal bleeding.

4. The slight separation of the woman's placenta from the uterine wall will not produce any bleeding.

Answer: 1

Explanation: 1. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding.

9) 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 a result of infertility treatment.

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

Answer: 1

Explanation: 1. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a woman with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.

10) In counseling a newly pregnant gravida 1 at 8 weeks' twin gestation, the nurse teaches the woman about the need for increased caloric intake. The nurse would tell the woman that the minimum recommended intake should be:

1. 2500 kcal and 120 g protein.

2. 3000 kcal and 150 g protein.

3. 3500 kcal and 175 g protein.

4. 4000 kcal and 190 g protein

Answer: 3

3. This is the recommended caloric and protein intake in a twin-gestation pregnancy.

11) When a woman who is experiencing a multiple fetal pregnancy asks, "What are the chances of having an uncomplicated pregnancy?" the nurse answers with which statement?

1. The perinatal mortality rate for monoamniotic siblings is 50 percent.

2. Twins are less likely to have complications than are singleton births.

3. Primiparous women pregnant with twins are less likely to develop complications.

4. Spontaneously conceived twins are less likely to develop complications.

Answer: 4

4. This is true. Spontaneously conceived twins are less likely to develop complications.

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

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

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

3. "This problem is common and will likely occur with my next pregnancy."

4. "Women with this condition usually go into labor after their due date."

Answer: 2

2. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the patient with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop.

13) 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 (select all that apply):

1. Chest pain, dyspnea, tachycardia, and hypotension.

2. Postmaturity syndrome.

3. Renal malformation or dysfunction.

4. Maternal diabetes.

5. Large-for-gestational-age infants.

Answer: 1, 2, 4

Explanation: 1. Chest pain, dyspnea, tachycardia, and hypotension are symptoms of amniotic embolism, which occurs more commonly with hydramnios. Hydramnios occurs in 10 to 20 percent of pregnant diabetics.

2. Renal malformation or dysfunction and postmaturity can cause oligohydramnios.

4. Hydramnios is not associated with maternal diabetes.

14) When caring for a laboring client with oligohydramnios, the nurse should be aware that (select all that apply):

1. There is an increased risk of cord compression.

2. There is less fluid available for the fetus to use during fetal breathing movements; therefore, pulmonary hypoplasia can develop, which could cause respiratory difficulties at birth.

3. Labor progress is often more rapid than average.

4. Early decelerations are more likely.

Answer: 1, 2, 4

Explanation: 1. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely.

2. There is less fluid available for the fetus to use during fetal breathing movements.

4. Decreased amniotic fluid can contribute to fetal head compression, which manifests itself in early decelerations.

15) Hydramnios most likely would be suspected when:

1. There is less amniotic fluid than normal for gestation.

2. The fundal height increases disproportionately to the gestation.

3. The woman has a twin gestation.

4. The quadruple screen comes back positive.

Answer: 2

2. The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.

16) Matching the four types of abruptio placenta with their location of separation.

1. The placenta separates at its edges, the blood passes

between the fetal membranes and the uterine wall, and the blood escapes vaginally.

2. Massive vaginal bleeding.

3. Separation occurs. May be minimal or moderate, can progress to complete separation.

4. The placenta, and the blood is trapped between the placenta and the uterine wall, bleeding results in concealed bleeding.

Explanation:

1: C-Marginal

2: A-Complete

3: B-Partial

4: D-Central

17) The nurse is caring for a G3P0 woman at 13 weeks' gestation experiencing cervical dilation and funneling. What risk factors may warrant prophylactic placement of a cerclage? Select all that apply.

1. Two previous second trimester pregnancy losses with relatively painless, early cervical dilation.

2. One previous third trimester pregnancy losses with painful cervical dilation.

3. Two early preterm births not related to infection, placental bleeding, preterm labor or multiple gestation.

4. One preterm birth (less than 36 weeks) not related to infection, placental bleeding, preterm labor or multiple gestation.

5. Three preterm births (less than 34 weeks) not related to infection, placental bleeding, preterm labor or multiple gestation.

Answer: 1, 5

Explanation: 1. This circumstance warrants placement of cerclage.

5. This circumstance warrants placement of cerclage.