Chapter 21 Childbirth at Risk: Labor-Related Complications

1) A client who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the client complains of chest pain and appears dyspneic. She is cyanotic and tachycardic, and her blood pressure has decreased to 78/36. What condition should the nurse suspect is developing?

1. Placenta accreta

2. Infection

3. Hypertensive crisis

4. Amniotic fluid embolus

Answer: 4

4. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.

2) A 20-year-old woman who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor?

1. Cephalopelvic disproportion (CPD)

2. Prolapsed cord

3. Placenta accreta

4. Occiput anterior (OA) fetal position

Answer: 1

Explanation: 1. The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed.

3) 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 gravida 6 at 39 weeks' gestation with twins

2. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes

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

4. 43-year-old gravida 2 at 37 weeks' gestation with hypertension

Answer: 1

Explanation: 1. Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern.

4) Two hours ago, the 39-weeks'-gestation client was 3 cm dilated, 40 percent 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 percent effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. The priority intervention would 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 anesthesia give the client an epidural.

Answer: 1

5) The primiparous client is at 42 weeks' gestation. What order should the nurse question?

1. Obtain biophysical profile today.

2. Begin nonstress test now.

3. Schedule labor induction for tomorrow.

4. Return to the clinic in one week.

Answer: 4

4. A post term pregnancy is high-risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments.

6) The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold's maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important?

1. Artificially rupture membranes.

2. Apply internal fetal scalp electrode.

3. Monitor maternal blood pressure every 15 minutes.

4. Alert the surgical team of urgent cesarean.

Answer: 4

4. This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture.

7) The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:

1. Shorter than average during the latent phase.

2. Prolonged with regard of the overall length of labor.

3. Rapid during transition.

4. Precipitous.

Answer: 2

2. The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.

8) 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? "Because my baby is big:

1. "I am at risk for excessive bleeding after delivery."

2. "His blood sugars could be high after he is born."

3. "My perineum could experience trauma during the birth."

4. "His shoulders could get stuck and a collar bone broken."

Answer: 2

2. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.

9) The laboring client has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100 to 105. Which nursing action is most important?

1. Change the mother's position from Fowler's to left lateral.

2. Insert a Foley catheter with the assistance of another nurse.

3. Notify the surgical team of an impending cesarean.

4. Decrease the IV of lactated Ringer's solution to 50 mL/hour.

Answer: 1

Explanation: 1. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.

10) The nurse is caring for a gravida 5 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's maneuver.

3. Obtain an order for pain medication.

4. Complete a sterile vaginal exam.

Answer: 4

4. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.

11) The charge nurse is reviewing charting on clients in the labor delivery triage unit. Which entry requires immediate intervention?

1. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath."

2. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis."

3. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for seven hours."

4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."

Answer: 4

4. Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.

12) The client at term has a suspected small pelvis. The fetus has an estimated weight of 4200 g (9 pounds 4 ounces). Spontaneous labor has begun, and the client is now at 6 cm. The nurse understands that the most important nursing action for this patient is to:

1. Assist the client to squat during the second stage.

2. Encourage oral fluids and carbohydrate intake.

3. Assess the cervix for change every eight hours.

4. Inform the couple that labor might be prolonged.

Answer: 1

Explanation: 1. Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.

13) 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. The nurse should prepare to:

1. Start an IV of lactated Ringer's.

2. Apply anti-embolism stockings.

3. Bottle feed the infant.

4. Send the placenta to pathology.

Answer: 1

Explanation: 1. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary.

14) The nurse is caring for a laboring client with known cephalopelvic disproportion (CPD). The woman develops tachysystolic labor patterns. Which possible course of treatment should the nurse anticipate?

1. Oxytocin administration

2. Cesarean section

3. Nipple stimulation

4. Amniotomy

Answer: 2

2. Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed.

15) The client has delivered a 4200 g fetus. The healthcare provider performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best? "The episiotomy extended and tore:

1. "Through your rectal mucosa."

2. "Up near your urethra."

3. "Into the muscle layer."

4. "Through your rectal sphincter."

Answer: 4

4. A third-degree laceration includes the rectal sphincter.

16) The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

1. Temperature 99.0°F

2. Platelet count 210,000/cmm

3. Fibrinogen level 50 mg/dL

4. Family refusing fetal autopsy

Answer: 3

3. Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the patient is in DIC.

17) Suspect ________ when labor is prolonged, ________ is slow, and ________ of the presenting part is delayed.

Answer: cephalopelvic disproportion, cervical effacement, engagement

18) Match the degree of laceration with its description.

1. Laceration involves the perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body; it may extend upward on one or both sides of the vagina.

2. Extends through the rectal mucosa to the lumen of the rectum.

3. Laceration is a superficial tear limited to the fourchette, perineal skin, and vaginal mucous membrane.

4. Laceration extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter.

________ A. First degree

________ B. Second degree

________ C. Third degree

________ D. Fourth degree

Answer: 1/B, 2/D, 3/A, 4/C

Explanation:

1: B-Second degree

2: D-Fourth degree

3: A-First degree

4: C-Third degree