Nursing Management of Labor and Birth at Risk

Nursing Management of Labor and Birth at Risk 1. The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? # Erratic § Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix. 2. The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? # Cervix dilates 1 cm per hour § A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation (dilatation). If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out. 3. The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? # Experience of additional back pain § Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter (dilation) dilatation stage of labor. OP position does not indicate the need to have the baby manually rotated, nor does it indicate a necessity for a vacuum extraction birth. 4. A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which finding? # Respiratory rate of 16 breaths/minute § A respiratory rate of 16 breaths per minute is appropriate and within acceptable parameters to continue the infusion. When administering magnesium sulfate, the nurse would immediately report decreased fetal heart rate variability, a urine output less than 30 ml/hour, and decreased or absent deep tendon reflexes. 5. A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: # Increasing birth weight § Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births. 6. A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? # Preterm labor § Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth. 7. A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? # Administer oxytocin diluted as a ÒpiggybackÓ infusion. § Oxytocin is always infused in a secondary or ÒpiggybackÓ infusion system so it can be halted quickly if overstimulation of the uterus occurs. 8. A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment post-birth? # Brachial plexus assessment § The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia. 9. A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? # Fetal heart tones § When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones. 10. A client is 2 weeks past her due date, and her health care provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply. # The fetus is in a longitudinal lie # The cervix is ripe # A presenting part is engaged § Before induction of labor is begun in term and post-term pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithinÐsphingomyelin ratio or ultrasound bi-parietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction. 11. The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? # 1 cm/hour for cervical dilation § In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation. 12. A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? # Offer to take pictures and footprints of the infant once it is delivered. § When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parentÕs approval. 13. A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? # Less than 3 hours § Precipitous labor is completed in less than 3 hours. 14. When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would be to: # Place her in a knee-chest position § Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a kneeÐchest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels. 15. A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? # The parents are beginning to demonstrate positive grieving behaviors. § An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able to give birth to a healthy child. Some infants will die. Outcome achievement might include the client begins positive grieving behaviors (touching, counting toes/fingers, etc.) in response to the loss of the newborn. The other statements are probably accurate but are not written as outcome statements. 16. The nurse provides education to a post-term pregnant client. What information will the nurse include to assist in early identification of potential problems? # ÒContinue to monitor fetal movements daily.Ó § The nurse will teach the post-term client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for post-term clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed. 17. A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counter-pressure on her lower back. What is the likely cause of the woman's back pain? # Occiput posterior position § A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor.Ó 18. A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? # Cesarean birth § If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD. 19. A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? # Assess fetal heart sounds § To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed. 20. A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? # Administer oxytocin § Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position. 21. Which action(s) will the nurse take when asked to apply suprapubic pressure during a birth with shoulder dystocia? Select all that apply. # Apply downward pressure just above the pubic bone # Apply pressure between contractions # Apply pressure at an angle toward the face of the fetus § Suprapubic pressure during a birth with shoulder dystocia is used to move the anterior shoulder under the pubic bone. The nurse would apply downward pressure just above the pubic bone, exert pressure at an angle toward the face of the fetus, and apply pressure between contractions. Downward pressure on the fundus of the uterus with the contractions is called fundal pressure, which is used to augment the pushing effort of the mother. 22. A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? # The 41-year-old client who conceived by in vitro fertilization § The nurse should assess infertility treatment as a contributor to the increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages. 23. Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? # Amniotic fluid embolism § With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. 24. The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: # 4,000 g to 4,500 g § Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions. 25. During a shoulder dystocia emergency, what action(s) does the nurse implement to prevent fetal hypoxia? Select all that apply. # Assist with maneuvers # Keep time # Document events in the record # Lower the head of the bed § The nurse will assist with the maneuvers used to facilitate birth of the shoulders. The nurse also keeps time, by calling out how much time has passed, since the head was delivered. The fetus needs to be completely birthed within 5 minutes to minimize the risk of hypoxia. Documentation of the events taking place, including the use of maneuvers and maternal and fetal response, is another nursing responsibility. The head of the bed needs to be lowered to a flat position to increase the effectiveness of McRoberts maneuver and to give the health care provider the maximum space to birth the shoulders. Oxytocin is not administered in this situation. The shoulders are stuck, and making the contractions stronger will not resolve the problem but will increase fetal distress. 26. The nurse is caring for a group of clients in labor and delivery. Which client is at greatest risk for placental abruption (abruptio placentae)? # 28 y.o G1 at 30 weeks' gestation with a blood pressure of 150/94 and history of cigarette § Hypertension and smoking are risk factors for placental abruption (abruptio placentae). Limited prenatal care, history of infertility or stillbirth, high BMI, and placenta previa are risk factors during a pregnancy, but they do not increase the risk of placental abruption. 27. A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? # External cephalic version § External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilation (dilatation) of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position. 28. The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? # Use McRoberts maneuver § McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion. 29. A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? # Depressed deep tendon reflexes § The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline. 30. The nurse would prepare a client for amnioinfusion when which action occurs? # Severe variable decelerations occur and are due to cord compression. § Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully; descent in the pelvis; abnormal fetal heart rate patterns or acute pulmonary edema; and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion. 31. A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum? # Identical § The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical). 32. Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? # A full bladder or rectum can impede fetal descent § Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent. 33. The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? # Placental abruption § The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM. 34. The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? # Late decelerations § When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression. 35. A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? # Uterine rupture § The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression. 36. The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? # Sudden shortness of breath § Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema. 37. When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: # Potential lacerations and bleeding § Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released. 38. A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? # Look for late decelerations on monitor, which is associated with fetal anoxia. § A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration. 39. A prenatal ultrasound reveals that a pregnant client has vasa previa. Which action by the nurse is appropriate? # Explain to the client about the need for a scheduled cesarean birth. § In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and, therefore, deliver before the fetus. The vessels may tear with cervical dilation (dilatation), just as a placenta previa may tear. Tearing would result in sudden fetal blood loss. Therefore, if the vasa previa is identified prenatally on ultrasound, a cesarean birth is scheduled prior to full term to prevent risks of spontaneous labor. Waiting until labor begins would increase the pregnant client's risk for vessel tearing. Neither oxytocin nor forceps would be used. 40. A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? # Magnesium sulfate § Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent. 41. A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the clientÕs history, which information would the nurse expect to find? # Gestational diabetes § Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or postterm pregnancy. Preterm pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet. 42. Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? # Continuing to monitor maternal and fetal status § Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus. 43. A client with a pendulous abdomen and uterine fibroids (uterine myomas) has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? # Transverse lie § A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroids (uterine myomas) that obstruct the lower uterine segment; contraction of the pelvic brim; congenital abnormalities of the uterus; or hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelvis. 44. A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? # Administer oxytocin § Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.