Chapter 19: Nursing Care during Obstetric Procedures McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition

The nurse knows that a urinary catheter is added to the instrument table if a forceps-

assisted birth is anticipated. What is the correct rationale for this intervention?

A. Spontaneous release of urine might contaminate the sterile field.

B. An empty bladder provides more room in the pelvis.

C. A sterile urine specimen is needed preoperatively.

D. A Foley catheter prevents the membranes from spontaneously rupturing.

ANS: B

Catheterization provides room for the application of the forceps blades and limits

bladder trauma. Urine is sterile. A clean- catch urinalysis is usually sufficient for

preoperative treatment. The membranes must be ruptured and the cervix completely

dilated for a forceps-assisted birth.

PTS: 1 REF: p. 385 | Box 17.2 MSC: Client Needs: Physiologic Integrity

DIF: Cognitive Level: Comprehension/Understanding

OBJ: Nursing Process: Implementation

After a forceps-assisted birth, the mother is observed to have continuous bright red lochia but

afirm fundus. What other finding is important to correlate with these data?

a. Mild, intermittent perineal pain

b. Edema and discoloration of the labia and perineum

c. Lack of an episiotomy

d. Lack of pain in the perineal area

ANS: B

Edema and discoloration of the labia and perineum along with continuous bright red

lochia and firm fundus are correlated with a vaginal wall hematoma. Perineal pain, lack of

episiotomy, and lack of pain are not correlated with a hematoma.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 386 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

Prior to cesarean birth, the nurse places the indwelling catheter and tubing in which manner?

A. Placed on the floor on a sterile drape

B. Placed near the head of the table

C. Clamped during the cesarean section

D.Positioned at the foot of the bed

ANS: B

The anesthesia clinician must monitor urine output during the surgery so the catheter and

tubing are placed near the head of the table. They are not placed on the floor, even on a

sterile drape. The catheter is not clamped because urinary output must be monitored

continuously. An early sign of hypovolemia is a decreasing urinary output.

PTS: 1 DIF: Cognitive Level: Application/Applyi

The nurse understands that which condition is a contraindication for an amniotomy?

a. Dilation less than 3 cm

b. Cephalic presentation

c. -2 station

d. Right occiput posterior position

ANS: C

A prolapsed cord can occur if the membranes artificially rupture when the presenting part is

not engaged. Engagement is assumed at zero station. The other conditions are not

contraindications to this procedure.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 376 OBJ: Nursing Process: Assessment

A nursing faculty member explains to students that which patient status is an acceptable

indication for serial oxytocin induction of labor?

a. Past 42 weeks' gestation

b. Multiple fetuses

c. Polyhydramnios

d. History of long labors

ANS: A

Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal

health. Multiple fetuses and polyhydramnios overdistend the uterus, making induction of

labor high risk. History of rapid labors is a reason for induction of labor because of the

possibility that the baby would otherwise be born in uncontrolled circumstances.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 378 OBJ: Integrated Process: Teaching-Learning

MSC: Client Needs: Health Promotion and Maintenance

The standard of care for obstetrics dictates that an internal version might be used

to manipulate the

A. fetus from a breech to a cephalic presentation before labor begins.

B. fetus from a transverse lie to a longitudinal lie before cesarean birth.

C. second twin from an oblique lie to a transverse lie before labor begins.

D. second twin from a transverse lie to a breech presentation during vaginal birth.

ANS: D

Internal version is used only during vaginal birth to manipulate the second twin into a

presentation that allows it to be born vaginally. For internal version to occur, the cervix needs

to be completely dilated; the cervix is not dilated before labor begins. An internal version

would not be done in the case of a cesarean birth.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integ

An indication for an episiotomy would be a woman who

a. has a routine vaginal birth.

b. has fetal shoulder dystocia.

c. is delivering a preterm infant.

d. has a history of rapid deliveries.

ANS: B

An episiotomy is indicated in the situation where the shoulder of the fetus becomes lodged

under the mother's symphysis pubis during birth. The other situations are not indications for

an episiotomy.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 387 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

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

A. trauma due to manipulation during delivery.

B. tachypnea due to maternal anesthesia.

C. prematurity due to miscalculation of gestation.

D. tachycardia due to maternal narcotics.

ANS: C

Regardless of the many criteria used to determine gestational age, inadvertent preterm

birth still occurs. There is reduced trauma with a cesarean birth. Maternal anesthesia may

cause respiratory distress. Maternal narcotics may cause respiratory distress.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 389 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

The nurse practicing in a labor setting knows that the woman most at risk for a uterine

rupture is a gravida

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

B. 2 who has had a low-segment vertical incision for delivery of a 10-pound infant.

C. 5 who has had two vaginal births and two cesarean births.

D. 4 who has had four cesarean births.

ANS: D

The risk of uterine rupture increases as the number of prior uterine incisions increases. More

than two previous cesarean births places the woman at increased risk for uterine rupture. The

other women are not high-risk candidates.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 388 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

The nurse caring for a woman in labor understands that the primary risk associated with

an amniotomy is

a. maternal infection.

b. maternal hemorrhage.

c. prolapse of the umbilical cord.

d. separation of the placenta

ANS: C

When the membranes are ruptured, the umbilical cord may come downward with the flow

of amniotic fluid and become trapped in front of the presenting part. Infection is a risk of

amniotomy but not the primary concern. Maternal hemorrhage is not associated with

amniotomy. Separation of the placenta may occur if the uterus is overdistended before the

amniotomy, but it is not the major concern.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 376 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

Before the physician performs an external version, the nurse should expect an order for a

a. tocolytic drug.

b. contraction stress test (CST).

c. local anesthetic.

d. indwelling catheter.

ANS: A

A tocolytic drug will relax the uterus before and during version, making manipulation easier.

A contraction stress test, local anesthetics, and indwelling catheters are not needed.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 383 OBJ: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

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.

ANS: B

A mother who is exhausted will be unable to assist with the expulsion of the fetus and is

a candidate for vacuum extraction. With a wide pelvic outlet and rapid delivery, vacuum

extraction is not necessary. A station of 0 is too high for a vacuum extraction.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 384 OBJ: Nursing Process: Assessment

After an amniotomy, which action by the nurse takes priority?

a. Assess the color of the amniotic fluid.

b. Change the patient's gown.

c. Estimate the amount of amniotic fluid.

d. Assess the fetal heart rate.

ANS: D

The fetal heart rate must be assessed immediately after the rupture of the membranes to

determine whether cord prolapse or compression has occurred. Assessing the amniotic fluid

color, changing the patient's gown, and estimating the amount of amniotic fluid lost are all

appropriate interventions but not the priority

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

a. A woman in active labor with contractions every 31 minutes lasting 60 seconds

each

b. A woman in transition with contractions every 2 minutes lasting 90 seconds each

C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to

80 seconds each

d. A woman in early labor with contractions every 5 minutes lasting 40 seconds each

ANS: B

This woman's contraction pattern represents hyperstimulation, and inadequate resting time

occurs between contractions to allow placental perfusion. The other women can continue

to use the oxytocin at this point.

PTS: 1 DIF: Cognitive Level: Analysis/Analyzing

REF: p. 378 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

The priority nursing care associated with an oxytocin (Pitocin) infusion is

a. measuring urinary output.

b. increasing infusion rate every 30 minutes.

c. monitoring uterine response.

d. evaluating cervical dilation.

ANS: C

Because of the risk of hyperstimulation, which could result in decreased placental

perfusion and uterine rupture, the nurse's priority intervention is monitoring uterine

response. Monitoring urinary output and cervical dilation is appropriate but not the priority.

The infusion rate may be increased but only after proper assessment determines that it is

appropriate.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 380 OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

Which event indicates a complication of an external version?

A. Maternal pulse rate of 100 bpm

B. Fetal bradycardia persisting 10 minutes after the version

C. Fetus returning to the original position

D. Increased maternal anxiety after the version

ANS: B

Fetal bradycardia after a version may indicate that the umbilical cord has become compressed,

and the fetus is having hypoxia. There are few risks to the woman during an external version. The

fetus may return to the original position, but this is not a complication of the version. Anxiety may

occur before the version but should decrease after the procedure is completed.

PTS: 1 DIF: Cognitive Level: Knowledge/Rememberin

Immediately after the forceps-assisted birth of an infant, which action by the nurse is next?

A. Assess the infant for signs of trauma.

B. Give the infant prophylactic antibiotics.

C. Apply a cold pack to the infant's scalp.

D. Measure the circumference of the infant's head.

ANS: A

Forceps delivery can result in local irritation, bruising, or lacerations of the fetal scalp.

Prophylactic antibiotics are not necessary with a forceps delivery. This would put the infant at

risk for cold stress and would be contraindicated. Measuring the circumference of the head is

part of the initial nursing assessment.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 386 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

When preparing a woman for a cesarean birth, the nurse's care should include

a. injection of narcotic preoperative medications.

b. full perineal shave preparation.

c. straight catheterization to empty the bladder.

d. administration of an oral antacid.

ANS: D

General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes

gastric acid and reduces potential lung injury if the woman vomits and aspirates gastric

contents during anesthesia. A narcotic at this point would put the fetus at high risk for

respiratory distress. Perineal preparation is not necessary for a cesarean section. Some

agencies will do an abdominal prep just before the surgery. The catheterization should be

indwelling in order to keep the bladder small during the surgery.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 389 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

Surgical, medical, or mechanical methods may be used for labor induction. Which

technique is considered a mechanical method of induction?

a. Amniotomy

b. Intravenous Pitocin

c. Transcervical catheter

d. Vaginal insertion of prostaglandins

ANS: C

Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of

induction. Other methods to expand and gradually dilate the cervix include Laminaria tents,

Dilapan, and Lamicel. Amniotomy is a surgical method of augmentation and induction.

Intravenous Pitocin is a medical method of induction. Insertion of prostaglandins is a

medical method of induction.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

What is an appropriate response to a woman's comment that she is worried about having a

cesarean birth?

A. "Don't worry. Everything will be okay."

B. "What are your feelings about having a cesarean birth?"

C. "I know you're worried, but this is a routine procedure."

D. "Patients commonly worry about surgery."

ANS: B

Allowing the patient to express her feelings is the most appropriate nursing response.

The nurse should never provide the patient with false reassurance or disregard or belittle

her feelings, which is what the other options do.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 391 | Nursing Care Plan

OBJ: Integrated Process: Communication and Documentation

MSC: Client Needs: Psychosocial Integrity

While assisting with a vacuum extraction birth, what should the nurse immediately report to

the provider?

A. Persistent fetal bradycardia below 100 bpm

B. Maternal pulse rate of 100 bpm

C. Maternal blood pressure of 120/70 mm Hg

D. Decrease in intensity of uterine contractions

ANS: A

Fetal bradycardia may indicate fetal distress and may require immediate intervention.

Maternal pulse rate may increase due to the pushing process. This blood pressure is within

expected norms for this stage of labor. The birth is imminent at this point.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 384 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

To monitor for potential hemorrhage in the woman who has just had a cesarean birth,

what action by the recovery room nurse is most appropriate?

A. Maintain an intravenous infusion at 100 mL/hr.

B. Assess the abdominal dressings for drainage.

C. Assess the uterus for firmness every 15 minutes.

d. Monitor her urinary output.

ANS: C

Maintaining contraction of the uterus is important in controlling bleeding from the

placental site. Maintaining proper fluid balance will not control hemorrhage. Assessing

abdominal dressings is an important assessment, but hemorrhage will first be noted

vaginally. Urinary output typically drops in hemorrhage, but this is a later finding.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 393 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

A new graduate nurse is preparing to hang oxytocin for a woman to augment her labor. What

action by the new nurse warrants intervention from the preceptor?

A. Adds oxytocin to the IV as a piggyback

B. Programs the IV pump for a primary infusion

C. Assesses FHR and uterine activity prior to starting the infusion

D. Attaches the infusion line to the proximal port

ANS: B

Oxytocin is run as a secondary infusion on a pump. When the new nurse programs it as the

primary infusion, the preceptor should intervene. Oxytocin should be added to the most

proximal IV port. FHR and uterine activity should be assessed prior to starting the infusion.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 379 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

A woman is receiving oxytocin to augment labor. The nurse notes that the Montevideo units

are measured at 560 and the fetus is showing late decelerations. What action by the nurse

takes priority?

A. Notify the charge nurse of the situation.

B. Document the findings in the chart.

C. Increase the rate of oxytocin slowly.

d. Stop the oxytocin infusion.

ANS: D

This woman is showing signs of uterine tachysystole. The nurse first turns the oxytocin

infusion off. Notifying the charge nurse and documentation are important but not the priority.

The nurse would not increase the rate of the infusion.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 382 | Safety Alert Box OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

A woman is going to have a vaccum extraction delivery. What nursing intervention is most

important to prevent complications?

a. Empty the woman's bladder.

b. Apply cold packs to the perineum.

c. Assess vital signs after the procedure.

d. Monitor the woman's temperature.

ANS: A

The nurse should empty the woman's bladder prior to vacuum extraction delivery. Ice packs

can help with pain and prevent or limit the size of hematomas, but that is not the most

important safety measure. Assessing vital signs will not prevent complications from

occurring but will help identify them when they occur.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 386 OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environme

The labor and delivery nurse must be cognizant of the specific conditions appropriate

for labor induction, including which of the following? (Select all that apply.)

a. Rupture of membranes at or near term

b. Convenience of the woman or her physician

c. Chorioamnionitis

d. Postterm pregnancy

e. Fetal death

ANS: A, C, D, E

Rupture of membranes at or near term, chorioamnionitis, postterm pregnancy, and fetal death

are all appropriate indications for induction of labor. Convenience is not.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: pp. 377-378 OBJ: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

The labor and delivery nurse learns that recommendations from ACOG related to VBAC risks

include which of the following? (Select all that apply.)

a. Immediate availability of the obstetric provider

b. Delivery at a tertiary care center

c. Availability of anesthesia personnel

d. Personnel who can assist with the cesarean birth

e. Use of misoprostol for cervical ripening

ANS: A, C, D

A VBAC delivery should only be attempted with the obstetric provider in house and

anesthesia along with operative personnel readily available to perform a cesarean birth.

VBAC deliveries may be done in community hospitals if appropriate policies and guidelines

for care are in place. Misoprostol administration is contraindicated in a patient with a

previous uterine scar.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 388 | Box 19.1 OBJ: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance