Ch 22: Labor Related problems

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Question Stem A patient who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the patient 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?

Stimulus

Answer Choice 1Placenta accreta

Rationale 1Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis.

Answer 1false

Choice 2Infection

Rationale 2This patients symptoms have a severe, sudden onset that is consistent with amniotic fluid embolus. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis.

Answer 2false

Choice 3Hypertensive crisis

Rationale 3The patient is hypotensive and is demonstrating signs and symptoms that are consistent with amniotic fluid embolus, including chest pain, dyspnea, tachycardia, hypotension and cyanosis.

Answer 3false

Choice 4Amniotic fluid embolus

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

Answer 4true

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Meta 4 Learning Outcome 1:LO07 - Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of the woman with an amniotic fluid embolus.

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Question Stem 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 patients labor?

Stimulus

Answer Choice 1Cephalopelvic disproportion (CPD)

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

Answer 1true

Choice 2Prolapsed cord

Rationale 2A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. This patient is demsontrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Answer 2false

Choice 3Placenta accreta

Rationale 3Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. This patient is demonstrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Answer 3false

Choice 4Occiput anterior (OA) fetal position

Rationale 4The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor. This patient is demonstrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Answer 4false

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Meta 4 Learning Outcome 1:LO03 - Relate the various types of fetal malposition and malpresentation to the nursing care management of each.

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Question Stem The nurse is making patient assignments for the next shift. Which patient is most likely to experience a complicated labor pattern?

Stimulus

Answer Choice 134-year-old gravida 6 at 39 weeks gestation with twins

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

Answer 1true

Choice 222-year-old gravida 1 at 23 weeks gestation with ruptured membranes

Rationale 2Although this patient is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this patient has no risk factors for an abnormal labor pattern.

Answer 2false

Choice 330-year-old gravida 3 at 41 weeks gestation and estimated fetal weight 7 pounds, 8 ounces

Rationale 3This patient has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.

Answer 3false

Choice 443-year-old gravida 2 at 37 weeks gestation with hypertension

Rationale 4Hypertension does not impact labor pattern; this patient has no risk factors for either hypertonic or hypotonic labor pattern development.

Answer 4false

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Meta 4 Learning Outcome 1:LO01 - Compare tachysystolic and hypotonic labor patterns, including risks, clinical therapy, and nursing care management.

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Question Stem Two hours ago, the 39-weeks-gestation patient was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every five minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every three minutes with 4050 seconds duration with intensity of 40 mmHg. The priority intervention would be:

Stimulus

Answer Choice 1Begin oxytocin after assessing for CPD.

Rationale 1The patient is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.

Answer 1true

Choice 2Give Terbutaline to stop the preterm labor.

Rationale 2Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped.

Answer 2false

Choice 3Start oxygen at 8 L/min.

Rationale 3Oxygen will not hurt, but it is not the priority.

Answer 3false

Choice 4Have anesthesia give the patient an epidural.

Rationale 4An epidural will not change the incoordinate contraction pattern.

Answer 4false

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Question Stem The primiparous patient is at 42 weeks gestation. What order should the nurse question?

Stimulus

Answer Choice 1Obtain biophysical profile today.

Rationale 1A biophysical profile is a commonly used assessment for the post-term fetus.

Answer 1false

Choice 2Begin nonstress test now.

Rationale 2The nonstress test is a commonly used assessment for the post-term fetus.

Answer 2false

Choice 3Schedule labor induction for tomorrow.

Rationale 3Labor induction is likely to occur with post-term pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation.

Answer 3false

Choice 4Return to the clinic in one week.

Rationale 4A 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.

Answer 4true

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Question Stem The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopolds maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What physician order is most important?

Stimulus

Answer Choice 1Artificially rupture membranes.

Rationale 1Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord.

Answer 1false

Choice 2Apply internal fetal scalp electrode.

Rationale 2An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord.

Answer 2false

Choice 3Monitor maternal blood pressure every 15 minutes.

Rationale 3The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way.

Answer 3false

Choice 4Alert the surgical team of urgent cesarean.

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

Answer 4true

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

Stimulus

Answer Choice 1Shorter than average during the latent phase.

Rationale 1Overall labor is often prolonged, not shorter.

Answer 1false

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

Rationale 2The 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.

Answer 2true

Choice 3Rapid during transition.

Rationale 3Overall labor is often prolonged, not more rapid.

Answer 3false

Choice 4Precipitous.

Rationale 4Overall labor is often prolonged, not precipitous.

Answer 4false

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Question Stem The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces). Which statement indicates that additional teaching is needed? Because my baby is big:

Stimulus

Answer Choice 1I am at risk for excessive bleeding after delivery.

Rationale 1Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk.

Answer 1false

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

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

Answer 2true

Choice 3My perineum could experience trauma during the birth.

Rationale 3Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus.

Answer 3false

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

Rationale 4Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.

Answer 4false

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Question Stem The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100105. Which nursing action is most important?

Stimulus

Answer Choice 1Change the mothers position from Fowlers to left lateral.

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

Answer 1true

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

Rationale 2If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.

Answer 2false

Choice 3Notify the surgical team of an impending cesarean.

Rationale 3The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.

Answer 3false

Choice 4Decrease the IV of lactated Ringers solution to 50 ml/hour.

Rationale 4Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the patient is hypotensive. Decreasing the IV rate will not improve fetal heart tones.

Answer 4false

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Question Stem 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?

Stimulus

Answer Choice 1Assess the odor of the amniotic fluid.

Rationale 1Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.

Answer 1false

Choice 2Perform Leopolds maneuver.

Rationale 2This assessment is not called for at this time.

Answer 2false

Choice 3Obtain an order for pain medication.

Rationale 3Pain medication is a low priority at this time.

Answer 3false

Choice 4Complete a sterile vaginal exam.

Rationale 4Checking 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.

Answer 4true

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Question Stem The charge nurse is reviewing charting on patients in the maternalchild triage unit. Which entry requires immediate intervention?

Stimulus

Answer Choice 1Primip at 24 weeks diagnosed with polyhydramnios: Patient reporting shortness of breath.

Rationale 1Although this patient is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency.

Answer 1false

Choice 2Multip at 32 weeks: Oligohydramnios per ultrasound secondary to fetal renal agenesis.

Rationale 2Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This patient will be grieving but is not experiencing physical complications.

Answer 2false

Choice 3Primip at 41 weeks: Patient reports leaking clear fluid from her vagina for seven hours.

Rationale 3Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This patient might be experiencing a complication, but it is a lower priority than the patient with the possibility of a prolapsed cord.

Answer 3false

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

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

Answer 4true

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Question Stem The patient at term has a suspected small pelvis. The fetus has an estimated weight of 4,200 g (9 pounds, 4 ounces). Spontaneous labor has begun, and the patient is now at 6 cm. The nurse understands that the most important nursing action for this patient is to:

Stimulus

Answer Choice 1Assist the patient to squat during the second stage.

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

Answer 1true

Choice 2Encourage oral fluids and carbohydrate intake.

Rationale 2A patient with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean. This patient should either be given only clear liquids or be n.p.o. to reduce the risk of aspiration should a cesarean need to be performed.

Answer 2false

Choice 3Assess the cervix for change every eight hours.

Rationale 3The cervix is normally assessed when the patients labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a patient was in the active phase of labor and cephalopelvic disproportion was a risk. Every eight hours is too far apart.

Answer 3false

Choice 4Inform the couple that labor might be prolonged.

Rationale 4Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority.

Answer 4false

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Question Stem The patient 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:

Stimulus

Answer Choice 1Start an IV of lactated Ringers.

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

Answer 1true

Choice 2Apply anti-embolism stockings.

Rationale 2Anti-embolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, anti-embolism stockings are not needed for this patient because manual removal of the placenta is not major surgery and does not lead to post-procedure immobility.

Answer 2false

Choice 3Bottle-feed the infant.

Rationale 3The patients partner or family member, or a nursery nurse, can feed the infant. The patient is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time.

Answer 3false

Choice 4Send the placenta to pathology.

Rationale 4The placenta might be sent to pathology after it is removed, but preparing the patient for manual removal of the placenta now is a higher priority.

Answer 4false

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

Stimulus

Answer Choice 1Oxytocin administration

Rationale 1Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD), a cesarean birth is indicated, as vaginal delivery cannot be performed.

Answer 1false

Choice 2Cesarean section


Answer 2true

Choice 3Nipple stimulation


Answer 3false

Choice 4Amniotomy


Answer 4false

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Question Stem The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? The episiotomy extended and tore:

Stimulus

Answer Choice 1Through your rectal mucosa.

Rationale 1A fourth-degree laceration is through the rectal mucosa.

Answer 1false

Choice 2Up near your urethra.

Rationale 2A periurethral laceration is near the urethra.

Answer 2false

Choice 3Into the muscle layer.

Rationale 3A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle.

Answer 3false

Choice 4Through your rectal sphincter.

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

Answer 4true

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Question Stem The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

Stimulus

Answer Choice 1Temperature 99.0F

Rationale 1Women with intrauterine fetal demise can become infected, but this temperature is not high enough to indicate infection.

Answer 1false

Choice 2Platelet count 210,000/cmm

Rationale 2Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count.

Answer 2false

Choice 3Fibrinogen level 50 mg/dL

Rationale 3Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200400 mg/dL. This is a very low fibrinogen level and indicates that the patient is in DIC.

Answer 3true

Choice 4Family refusing fetal autopsy

Rationale 4Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority.

Answer 4false

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Ch 22: Labor Related problems

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Transcript of Ch 22: Labor Related problems