Chapter 17: Labor and Birth Complications Nursing School Test Banks

Chapter 17: Labor and Birth Complications

MULTIPLE CHOICE

1. In planning for home care of a woman with preterm labor, which concern must the nurse address?

a.

Nursing assessments will be different from those done in the hospital setting.

b.

Restricted activity and medications will be necessary to prevent recurrence of preterm labor.

c.

Prolonged bed rest may cause negative physiologic effects.

d.

Home health care providers will be necessary.

ANS: C

Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many women will receive home health nurse visits, but care is individualized for each woman.

PTS: 1 DIF: Cognitive Level: Analysis REF: 446

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

2. The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?

a.

Assessing deep tendon reflexes (DTRs)

b.

Assessing for chest discomfort and palpitations

c.

Assessing for bradycardia

d.

Assessing for hypoglycemia

ANS: B

Terbutaline is a b2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. b2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 447

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects?

a.

Urine output of 160 mL in 4 hours

b.

Deep tendon reflexes 2+ and no clonus

c.

Respiratory rate of 16 breaths/min

d.

Serum magnesium level of 10 mg/dL

ANS: D

The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 448

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

4. A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:

a.

Stimulate fetal surfactant production.

b.

Reduce maternal and fetal tachycardia associated with ritodrine administration.

c.

Suppress uterine contractions.

d.

Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

ANS: A

Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 450

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

5. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?

a.

Estriol is not found in maternal saliva.

b.

Irregular, mild uterine contractions are occurring every 12 to 15 minutes.

c.

Fetal fibronectin is present in vaginal secretions.

d.

The cervix is effacing and dilated to 2 cm.

ANS: D

Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.

PTS: 1 DIF: Cognitive Level: Application REF: 461

OBJ: Nursing Process: Assessment, Planning

MSC: Client Needs: Health Promotion and Maintenance

6. A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this womans labor?

a.

She is exhibiting hypotonic uterine dysfunction.

b.

She is experiencing a normal latent stage.

c.

She is exhibiting hypertonic uterine dysfunction.

d.

She is experiencing pelvic dystocia.

ANS: C

Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. The contraction pattern seen in this woman signifies hypertonic uterine activity. Typically uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

PTS: 1 DIF: Cognitive Level: Application REF: 455

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

7. Which assessment is least likely to be associated with a breech presentation?

a.

Meconium-stained amniotic fluid

b.

Fetal heart tones heard at or above the maternal umbilicus

c.

Preterm labor and birth

d.

Post-term gestation

ANS: D

Post-term gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.

PTS: 1 DIF: Cognitive Level: Analysis REF: 457

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?

a.

Prolonged latent phase

c.

Arrest of active phase

b.

Protracted active phase

d.

Protracted descent

ANS: C

With an arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 455

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

9. In evaluating the effectiveness of oxytocin induction, the nurse would expect:

a.

Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.

b.

The intensity of contractions to be at least 110 to 130 mm Hg.

c.

Labor to progress at least 2 cm/hr dilation.

d.

At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

ANS: A

The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min.

PTS: 1 DIF: Cognitive Level: Analysis REF: 466

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

10. In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, which information would the nurse include?

a.

Because this is a repeat procedure, you are at the lowest risk for complications.

b.

Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures.

c.

Because this is your second cesarean birth, you will recover faster.

d.

You will not need preoperative teaching because this is your second cesarean birth.

ANS: B

Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures is the most appropriate statement. It is not accurate to state that the woman is at the lowest risk for complications. Both maternal and fetal risks are associated with every cesarean section. Because this is your second cesarean birth, you will recover faster is not an accurate statement. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed, regardless of whether the client has already had this procedure.

PTS: 1 DIF: Cognitive Level: Application REF: 469

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

11. For a woman at 42 weeks of gestation, which finding would require further assessment by the nurse?

a.

Fetal heart rate of 116 beats/min

b.

Cervix dilated 2 cm and 50% effaced

c.

Score of 8 on the biophysical profile

d.

One fetal movement noted in 1 hour of assessment by the mother

ANS: D

Self-care in a post-term pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. Normal findings in a 42-week gestation include fetal heart rate of 116 beats/min, cervix dilated 20 cm and 50% effaced, and a score of 8 on the biophysical profile.

PTS: 1 DIF: Cognitive Level: Application REF: 452

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. A pregnant womans amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority?

a.

Placing the woman in the knee-chest position

b.

Covering the cord in sterile gauze soaked in saline

c.

Preparing the woman for a cesarean birth

d.

Starting oxygen by face mask

ANS: A

The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

PTS: 1 DIF: Cognitive Level: Application REF: 478

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:

a.

Enhance uteroplacental perfusion in an aging placenta.

b.

Increase amniotic fluid volume.

c.

Ripen the cervix in preparation for labor induction.

d.

Stimulate the amniotic membranes to rupture.

ANS: C

It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.

PTS: 1 DIF: Cognitive Level: Application REF: 463

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

14. A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate?

a.

After the baby is born.

b.

When we can stabilize your preterm labor and arrange home health visits.

c.

Whenever the doctor says that it is okay.

d.

It depends on what kind of insurance coverage you have.

ANS: B

The clients preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a woman with preterm labor is multifactorial; the goal is to prevent delivery. In many cases this may be achieved at home. Care of the preterm client is multidisciplinary and multifactorial. Managed care may dictate earlier hospital discharges or a shift from hospital to home care. Insurance coverage may be one factor in the care of clients, but ultimately client safety remains the most important factor.

PTS: 1 DIF: Cognitive Level: Application REF: 447

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

15. The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of:

a.

Uterine contractions occurring every 8 to 10 minutes.

b.

A fetal heart rate (FHR) of 180 with absence of variability.

c.

The clients needing to void.

d.

Rupture of the clients amniotic membranes.

ANS: B

This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The clients needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the clients membranes have ruptured.

PTS: 1 DIF: Cognitive Level: Evaluation REF: 449

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

16. Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance:

a.

The terms preterm birth and low birth weight can be used interchangeably.

b.

Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.

c.

Low birth weight is anything below 3.7 pounds.

d.

In the United States early in this century, preterm birth accounted for 18% to 20% of all births.

ANS: B

Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 pounds. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 441

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. With regard to the care management of preterm labor, nurses should be aware that:

a.

Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms.

b.

Braxton Hicks contractions often signal the onset of preterm labor.

c.

Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver.

d.

The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANS: D

Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 445

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

18. As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:

a.

The drugs can be given efficaciously up to the designated beginning of term at 37 weeks.

b.

There are no important maternal (as opposed to fetal) contraindications.

c.

Its most important function is to afford the opportunity to administer antenatal glucocorticoids.

d.

If the client develops pulmonary edema while receiving tocolytics, intravenous (IV) fluids should be given.

ANS: C

Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 450

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

19. With regard to dysfunctional labor, nurses should be aware that:

a.

Women who are underweight are more at risk.

b.

Women experiencing precipitous labor are about the only dysfunctionals not to be exhausted.

c.

Hypertonic uterine dysfunction is more common than hypotonic dysfunction.

d.

Abnormal labor patterns are most common in older women.

ANS: B

Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women less than 20 years of age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 455

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

20. The least common cause of long, difficult, or abnormal labor (dystocia) is:

a.

Midplane contracture of the pelvis.

b.

Compromised bearing-down efforts as a result of pain medication.

c.

Disproportion of the pelvis.

d.

Low-lying placenta.

ANS: C

The least common cause of dystocia is disproportion of the pelvis.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 455

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

21. Nurses should be aware that the induction of labor:

a.

Can be achieved by external and internal version techniques.

b.

Is also known as a trial of labor (TOL).

c.

Is almost always done for medical reasons.

d.

Is rated for viability by a Bishop score.

ANS: D

Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 461

OBJ: Nursing Process: Diagnosis

MSC: Client Needs: Safe and Effective Care Environment

22. While caring for the patient who requires an induction of labor, the nurse should be cognizant that:

a.

Ripening the cervix usually results in a decreased success rate for induction.

b.

Labor sometimes can be induced with balloon catheters or laminaria tents.

c.

Oxytocin is less expensive than prostaglandins and more effective but creates greater health risks.

d.

Amniotomy can be used to make the cervix more favorable for labor.

ANS: B

Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 462

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

23. With regard to the process of augmentation of labor, the nurse should be aware that it:

a.

Is part of the active management of labor that is instituted when the labor process is unsatisfactory.

b.

Relies on more invasive methods when oxytocin and amniotomy have failed.

c.

Is a modern management term to cover up the negative connotations of forceps-assisted birth.

d.

Uses vacuum cups.

ANS: A

Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 465

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

24. The nurse providing care to a woman in labor should understand that cesarean birth:

a.

Is declining in frequency in the twenty-first century in the United States.

b.

Is more likely to be performed for poor women in public hospitals who do not receive the nurse counseling as do wealthier clients.

c.

Is performed primarily for the benefit of the fetus.

d.

Can be either elected or refused by women as their absolute legal right.

ANS: C

The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. Cesarean births are increasing in the United States in this century. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A womans right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 471

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

25. To provide safe care for the woman, the nurse understands that which condition is a contraindication for an amniotomy?

a.

Dilation less than 3 cm

c.

-2 station

b.

Cephalic presentation

d.

Right occiput posterior position

ANS: C

The dilation of the cervix must be great enough to determine labor. The presenting part of the fetus should be engaged and well applied to the cervix before the procedure in order to prevent cord prolapse. Amniotomy is deferred if the presenting part is higher in the pelvis. ROP indicates a cephalic presentation, which is appropriate for an amniotomy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 464

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

26. The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births.

a.

Viral

c.

Cervical

b.

Periodontal

d.

Urinary tract

ANS: A

The infections that increase the risk of preterm labor and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the client to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labor and birth. The presence of urinary tract infections increases the risk of preterm labor and birth.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 443

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

27. Which patient status is an acceptable indication for serial oxytocin induction of labor?

a.

Past 42 weeks gestation

c.

Polyhydramnios

b.

Multiple fetuses

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 overdistend the uterus and make induction of labor high risk. Polyhydramnios overdistends the uterus, again 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 REF: 453

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

28. The standard of care for obstetrics dictates that an internal version may 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.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 460

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

29. The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is:

a.

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

b.

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

c.

A gravida 5 who had two vaginal births and two cesarean births.

d.

A gravida 4 who has had all cesarean births.

ANS: D

The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 479

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Tocolytic drug.

c.

Local anesthetic.

b.

Contraction stress test (CST).

d.

Foley catheter.

ANS: A

A tocolytic drug will relax the uterus before and during version, thus making manipulation easier. CST is used to determine the fetal response to stress. A local anesthetic is not used with external version. The bladder should be emptied; however, catheterization is not necessary.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 460

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

31. A maternal indication for the use of vacuum extraction is:

a.

A wide pelvic outlet.

c.

A history of rapid deliveries.

b.

Maternal exhaustion.

d.

Failure to progress past 0 station.

ANS: B

A mother who is exhausted may be unable to assist with the expulsion of the fetus.

The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum extraction.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 468

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

32. The priority nursing intervention after an amniotomy should be to:

a.

Assess the color of the amniotic fluid.

b.

Change the patients 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. Secondary to FHR assessment, amniotic fluid amount, color, odor, and consistency is assessed.

Dry clothing is important for patient comfort; however, it is not the top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 469

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

33. 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 nurses priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 464

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

34. Immediately after the forceps-assisted birth of an infant, the nurse should:

a.

Assess the infant for signs of trauma.

b.

Give the infant prophylactic antibiotics.

c.

Apply a cold pack to the infants scalp.

d.

Measure the circumference of the infants head.

ANS: A

The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.

PTS: 1 DIF: Cognitive Level: Application REF: 467

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

35. Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction?

a.

Amniotomy

c.

Transcervical catheter

b.

Intravenous Pitocin

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 hydroscopic dilators such as laminaria tents (made from desiccated seaweed), or Lamicel (contains magnesium sulfate). Amniotomy is a surgical method of augmentation and induction.

Intravenous Pitocin and insertion of prostaglandins are medical methods of induction.

PTS: 1 DIF: Cognitive Level: Application REF: 462

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

36. The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation (Select all that apply)?

a.

Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency

b.

Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency

c.

Uterine tone <20 mm Hg

d.

Uterine tone >20 mm Hg

e.

Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern

ANS: B, D, E

Uterine contractions that occur less than 2 minutes apart and last more than 90 seconds, a uterine tone of over 20 mm Hg, and a nonreassuring FHR and pattern are all indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone of less than 20 mm Hg is normal.

PTS: 1 DIF: Cognitive Level: Analysis REF: 464

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

37. Complications and risks associated with cesarean births include (Select all that apply):

a.

Placental abruption.

b.

Wound dehiscence.

c.

Hemorrhage.

d.

Urinary tract infections.

e.

Fetal injuries.

ANS: B, C, D, E

Placental abruption and placenta previa are both indications for cesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with delivery by cesarean section.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 471

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

38. Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include (Select all that apply):

a.

Rupture of membranes at or near term.

b.

Convenience of the woman or her physician.

c.

Chorioamnionitis (inflammation of the amniotic sac).

d.

Post-term pregnancy.

e.

Fetal death.

ANS: A, C, D, E

These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks completed gestation.

PTS: 1 DIF: Cognitive Level: Application REF: 461

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

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