Chapter 10: High-Risk Labor and Birth Nursing School Test Banks

Chapter 10: High-Risk Labor and Birth

Multiple Choice

1. During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2 minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action?
a. Increase oxytocin infusion rate per physicians protocol.
b. Stop oxytocin infusion immediately.
c. Maintain present oxytocin infusion rate and continue to assess.
d. Decrease oxytocin infusion rate by 2 mU/min and report to physician.

ANS: c
Feedback
a. Increasing the oxytocin infusion could result in uterine hyperstimulation.
b. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped.
c. Correct. Maintain present oxytocin infusion rate and continue to assess is the correct response, as this question describes a normal uterine contraction pattern.
d. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped or decreased.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate

2. If the umbilical cord prolapses during labor, the nurse should immediately:
a. Type and cross-match blood for an emergency transfusion.
b. Await MD order for preparation for an emergency cesarean section.
c. Attempt to reposition the cord above the presenting part.
d. Apply manual pressure to the presenting part to relieve pressure on the cord.

ANS: d
Feedback
a. Type and cross-match is one of the interventions with cord prolapse but not a priority.
b. Awaiting MD intervention is not appropriate as umbilical cord prolapse is an obstetrical emergency requiring immediate intervention.
c. Once the cord has prolapsed, it cannot be repositioned.
d. Apply manual pressure to the presenting part to relieve pressure on the cord represents the first nursing intervention to attempt to improve circulation to the fetus.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

3. Augmentation of labor:
a. Is part of the active management of labor instituted when the labor process is unsatisfactory and uterine contractions are inadequate
b. Relies on more invasive methods when oxytocin and amniotomy have failed
c. Is elective induction of labor
d. Is an operative vaginal delivery that uses vacuum cups

ANS: a
Feedback
a. Augmentation stimulates uterine contractions after labor has started but not progressed appropriately.
b. Augmentation uses amniotomy and oxytocin.
c. Augmentation stimulates labor.
d. Vacuum delivery is not part of augmentation of labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

4. Your patient is a 28-year-old gravida 2 para 1 in active labor. She has been in labor for 12 hours. Upon further assessment, the nurse determines that she is experiencing a hypotonic labor pattern. Possible maternal and fetal implications from hypotonic labor patterns are:
a. Intrauterine infection and maternal exhaustion with fetal distress usually occurring early in labor.
b. Intrauterine infection and maternal exhaustion with fetal distress usually occurring late in labor.
c. Intrauterine infection and postpartum hemorrhage with fetal distress early in labor.
d. Intrauterine infection and ruptured uterus and fetal death.

ANS: b
Feedback
a. The risk of hypotonic labor occurs later in labor.
b. Hypotonic labor patterns increase risk for infection and maternal exhaustion, with fetal distress occurring late in labor as hypotonic patterns prolong labor.
c. There is not an increased risk of postpartum hemorrhage or fetal distress in early labor.
d. Hypotonic patterns do not result in rupture of the uterus.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Moderate

5. A primigravida woman at 42 weeks gestation received Prepidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which of the following actions by the nurse is appropriate?
a. Perform Nitrazine analysis of the amniotic fluid.
b. Report the lack of progress to the obstetrician.
c. Place the woman on her left side.
d. Ask the doctor for an order for oxytocin.

ANS: b
Feedback
a. There is nothing in the scenario that implies that the membranes may have ruptured.
b. Little progress has taken place. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective.
c. There is nothing in the scenario that implies that the patient needs to be placed on her side.
d. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective.

KEY: Integrated Processes: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Unexpected Response to Medication | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Difficult

6. The nurse is assisting a physician in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time?
a. Risk for injury
b. Colonic constipation
c. Risk for impaired parenting
d. Ineffective individual coping

ANS: a
Feedback
a. There is a risk for injury. For example, the patient could suffer a cervical, vaginal, or perineal laceration.
b. A diagnosis of colonic constipation is unrelated to the fact that the baby was delivered by forceps.
c. There is nothing in the scenario that implies that the patient is at risk for impaired parenting.
d. There is nothing in the scenario that implies that the patient is at risk for ineffective individual coping.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

7. Four women are close to delivery on the labor and delivery unit. The nurse knows to be vigilant to the signs of neonatal respiratory distress in which delivery?
a. 42-week-gestation pregnancy complicated by intrauterine growth restriction
b. 41-week-gestation pregnancy with biophysical profile score of 10 that morning
c. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams
d. 39-week-gestation pregnancy complicated by maternal cholecystitis

ANS: a
Feedback
a. A post-term baby with intrauterine growth restriction (IUGR) is high risk for meconium aspiration syndrome, cold stress syndrome, hypoglycemia, and acidosis. In each case, the baby may exhibit signs of respiratory distress.
b. A biophysical profile (BPP) of 10 is a normal finding.
c. The normal birth weight is between 2500 and 4000 grams.
d. Maternal gallbladder disease does not place the baby in danger of developing respiratory distress.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Planning | Cognitive Level: Analysis | Content Area: Intrapartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Potential for Complications of Delivery | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

8. You are caring for a primiparous woman admitted to labor and delivery for induction of labor at 42 weeks gestation. She asks you to explain the factors that contribute to prolonged labor. The best response would be to state the following:
a. Primiparous women are not at risk for dystocia because they usually have small babies.
b. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of the mother, and psychosocial response.
c. Labor is primarily associated with pelvic abnormalities.
d. Dystocia is typically diagnosed prior to labor based on pelvimetry.

ANS: b
Feedback
a. Dystocia is not exclusively related to fetal size and being primiparous.
b. This is the only correct definition of prolonged labor and dystocia. The success of any labor depends on the complex interrelationship of several factors: fetal size, presentation, position, size and shape of the pelvis, and quality of uterine contractions.
c. Pelvic abnormality is the least important contributor to dystocia.
d. Dystocia is diagnosed during, not prior to, labor.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application and Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult
9. A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4, fetal heart rate 140s with good variability and no decelerations, TPR 98.6F, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)?
a. Bishop score of 5
b. Fetal heart of 152 bpm
c. Respiratory rate of 24 rpm
d. Contraction frequency of every 2 minutes

ANS: d
Feedback
a. A Bishop score of 9 or higher indicates that the primigravida womans cervix is ripe.
b. A fetal heart rate of 152 is within normal limits for this fetus.
c. A respiratory rate of 24 is within normal limits.
d. Cervidil should be removed for tachysystole.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Difficult

10. A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations should the nurse advise the patient that her request may be declined?
a. Transverse fetal lie
b. Flexed fetal attitude
c. Previous low flap uterine incision
d. Positive vaginal candidiasis

ANS: a
Feedback
a. A baby in the transverse lie is lying sideways in the uterus. This lie is incompatible physiologically with a vaginal delivery.
b. A baby in the flexed fetal attitude is in a physiologic position for a vaginal delivery.
c. A previous low flap uterine incision is not incompatible physiologically with a vaginal delivery.
d. A positive vaginal Candidiasis culture is not an indication for cesarean birth.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Comprehension | Content Area: Intrapartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

11. The physician has ordered intravenous oxytocin for induction for four gravidas. In which of the following situations should the nurse refuse to comply with the order?
a. Primigravida with complete placenta previa
b. Multigravida with extrinsic asthma
c. Primigravida who is 38 years old
d. Multigravida who is colonized with group B streptococci

ANS: a
Feedback
a. The nurse should refuse to comply with this order because labor is contraindicated for a patient with complete placenta previa. This patient will have to be delivered via cesarean section.
b. Induction is not contraindicated for patients with asthma.
c. Induction is not contraindicated for patients who are 38 years old.
d. Induction is not contraindicated for patients with group B streptococci.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Adverse Effects/Contraindications; Intrapartum Care; Pharmacological and Parenteral Therapies: Intravenous Therapies | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Difficult

12. The perinatal nurse notes a rapid decrease in the fetal heart rate that does not recover immediately following an amniotomy. The most likely cause of this obstetrical emergency is:
a. Prolapsed umbilical cord
b. Vasa previa
c. Oligohydramnios
d. Placental abruption

ANS: a
Feedback
a. The nurse needs to assess the fetal heart rate immediately before and after the artificial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such as bradycardia and variable decelerations may be indicative of cord compression or prolapse.
b. Vasa previa is abnormal insertion of the cord into the placenta
c. Oligohydramnios is a decreased amount of amniotic fluid.
d. Placenta abruption is separation of the placenta from the uterine wall. In this scenario, prolapsed cord is the most likely cause of the abrupt deceleration in the FHR.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

13. During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurses most appropriate action is to notify the physician/certified nurse midwife and describe a:
a. Need for vaginal assessment and repair
b. Requirement for an oxytocin infusion
c. Need for further information for the woman/family about forceps
d. Requirement for bladder assessment and catheterization

ANS: a
Feedback
a. In the presence of a firm fundus and bright red bleeding, after a forceps-assisted birth there is a need for vaginal assessment and there may be a need for repair.
b. The fundus is firm, and oxytocin is not indicated.
c. There is no indication in this scenario that the family needs more information.
d. There is no indication in this scenario that the bladder is contributing to the bleeding.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

14. The perinatal nurse is providing care to Carol, a 28-year-old multiparous woman in labor. Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as strong. Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling some rectal pressure. Carol is most likely experiencing:
a. Hypertonic contractions
b. Hypotonic contractions
c. Precipitous labor
d. Uterine hyperstimulation

ANS: c
Feedback
a. Hypertonic contractions result in little cervical change.
b. Hypotonic contractions result in little cervical change.
c. Contrary to both hypertonic and hypotonic labor, precipitate labor contractions produce very rapid, intense contractions. A precipitous labor lasts less than 3 hours from the beginning of contractions to birth. Patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor.
d. Patients with precipitous labor often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor. Precipitous labor contractions produce very rapid, intense contractions.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Multiple Response

15. Hyperstimulation is defined as:
a. Contractions lasting more than 2 minutes
b. Five or more contractions in 10 minutes
c. Contractions occurring within 1 minute of each other
d. Uterine resting tone below 20 mm/Hg

ANS: a, b, c
Contractions lasting more than 2 minutes, five or more contractions in 10 minutes, and contractions occurring within 1 minute of each other describe the criteria for hyperstimulation. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy
16. Documentation related to vacuum delivery includes which of the following:
a. Fetal heart rate
b. Timing and number of applications
c. Position and station of fetal head
d. Maternal position

ANS: a, b, c
Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

17. Contraindications for induction of labor include:
a. Abnormal fetal position
b. Postdated pregnancy
c. Pregnancy-induced hypertension
d. Placental abnormalities

ANS: a, d
Contraindications for induction of labor include abnormal fetal position because of the risk of fetal injury and placental abnormalities because of the risk of hemorrhage. Pregnancy-induced hypertension and placental abnormalities are two of the common indications for induction of labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

18. Documentation related to vacuum delivery includes which of the following:
a. Fetal heart rate
b. Timing and number of applications
c. Position and station of fetal head
d. Maternal position

ANS: a, b, c
Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult
True/False

19. The perinatal nurse includes the following when explaining the physiology of artificial rupture of membranes to the student nurse: rupture of membranes causes a release of arachidonic acid, which converts to prostaglandins, substances known to stimulate oxytocin in the pregnant uterus.

ANS: True
At certain points in the labor, an amniotomy, or artificial rupture of the membranes, may be successful in increasing uterine contractility.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

20. The perinatal nurse describes asynclitism to students as a presentation that occurs when the fetal head is turned toward the maternal sacrum or symphysis at an oblique angle.

ANS: True
Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part. These presentations are uncommon and are usually associated with fetal anomalies.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

21. The perinatal nurse explains to the student nurse that the most frequent fetal risk associated with the use of forceps is cord compression.

ANS: False
The most frequent fetal risk associated with the use of forceps is superficial scalp or facial marks that will resolve quickly.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

Fill-in-the-Blank

22. The perinatal nurse prepares for two potential complications that may accompany a precipitous labor and birth: postpartum __________ and a need for neonatal __________.

ANS: hemorrhage; resuscitation
Feedback 1: Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rupture and vaginal lacerations. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage related to the rapid birth.
Feedback 2: Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rupture and vaginal lacerations. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage related to the rapid birth.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

23. The perinatal nurse understands that the most appropriate nursing action following an amniotomy is an assessment of the __________ as well as the __________ and __________ of the amniotic fluid.

ANS: fetal heart rate; color; odor
The nurse carefully monitors the patient who will undergo an amniotomy. Vital signs, cervical effacement and dilation, station of the presenting part, fetal heart rate, and color and amount of amniotic fluid are assessed.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

24. The perinatal nurse caring for a laboring woman who is receiving an oxytocin infusion documents the following information: rate of __________, frequency and strength of __________, fetal __________, and cervical __________ and __________.

ANS: infusion; contractions; heart rate; dilatation; effacement
Oxytocin protocols in many institutions require that the nurse remain at the patients bedside at all times for careful surveillance. The following data should be placed on a flow sheet in the patient record: patients vital signs, fetal heart rate, frequency, duration and strength of contractions, cervical effacement and dilatation, fetal station and lie, rate of oxytocin infusion intake and urine output, and the psychological response of the patient.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Moderate

25. The perinatal nurse recognizes that the laboring multiparous patient who is attempting a vaginal birth following a previous cesarean birth (VBAC) needs frequent assessments to ensure that there is __________ during her labor.

ANS: progress
Women with a previous history of cesarean birth may be offered a trial of labor, although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

26. During labor, oxytocin is always administered __________.

ANS: intravenously with an infusion pumpDuring labor, oxytocin can only be administered intravenously via an infusion pump to titrate and regulate the dose for safe administration.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate

27. __________ is contraindicated with shoulder dystocia.

ANS: Fundal pressureFundal pressure is contraindicated with shoulder dystocia because it may further impact the shoulder and increases risk of fetal injury.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

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