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Ch 27 The Woman with an Intrapartum Complication
Terms in this set (30)
1. Which actions by the nurse may prevent infections in the labor and delivery area?
a. Vaginal examinations every hour while the woman is in active labor
b. Use of clean techniques for all procedures
c. Cleaning secretions from the vaginal area by using back-to-front motion
d. Keeping underpads and linens as dry as possible
A Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.
B Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured.
C Vaginal drainage should be removed with a front-to-back motion to decrease fecal contamination.
D Bacterial growth prefers a moist, warm environment.
2. A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for at-home continuation of the tocolytic effect?
c. Calcium gluconate
d. Magnesium sulfate
A Ritodrine is the only drug approved by the FDA for tocolysis; however, it is rarely used because of significant side effects.
B The woman receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis.
C Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy.
D Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.
3. Which technique is least effective for the woman with persistent occiput posterior position?
a. Lie supine and relax.
b. Sit or kneel, leaning forward with support.
c. Rock the pelvis back and forth while on hands and knees.
A Lying supine increases the discomfort of "back labor."
B A sitting or kneeling position may help the fetal head to rotate to occiput anterior.
C Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.
D Squatting aids both rotation and fetal descent.
4. Birth for the nulliparous woman with a fetus in a breech presentation is usually by
a. Cesarean delivery
b. Vaginal delivery
c. Forceps-assisted delivery
d. Vacuum extraction
A Delivery for the nulliparous woman with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so that the infant can breathe.
B The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so the infant can breathe.
C The physician may assist rotation of the head with forceps. A cesarean birth may be required.
D Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult.
5. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?
a. A primigravida who is 17 years old
b. A 22-year-old multiparous woman with ruptured membranes
c. A multiparous woman at 39 weeks of gestation who is expecting twins
d. A primigravida woman who has requested no analgesia during her labor
A A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction.
B There is no indication that this woman's uterus is overdistended, which is the main cause of hypotonic dysfunction.
C Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly.
D A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
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 woman's 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.
A With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor and then the contractions become weak and inefficient or stop altogether.
B The contraction pattern seen in this woman signifies hypertonic uterine activity.
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.
D 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.
7. 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
b. Protracted active phase
c. Secondary arrest
d. Protracted descent
A In the nulliparous woman, a prolonged latent phase typically lasts more than 20 hours.
B A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation).
C With a secondary arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, indicating an arrest of labor.
D With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?
a. Incomplete uterine relaxation
b. Maternal fatigue and exhaustion
c. Maternal sedation with narcotics
d. Administration of tocolytic drugs
A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases fetal oxygen supply.
B Maternal fatigue usually does not decrease uterine blood flow.
C Maternal sedation will sedate the fetus but should not decrease blood flow.
D Tocolytic drugs decrease contractions. This will increase uterine blood flow.
9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should
a. Give supplemental oxygen with a small facemask.
b. Encourage the parents to hold the infant.
c. Palpate the infant's clavicles.
d. Perform a complete newborn assessment.
A The Apgar indicates that no respiratory interventions are needed.
B The infant needs to be assessed for clavicle fractures before excessive movement.
C Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up.
D A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.
10. A laboring patient in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?
a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger."
b. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain."
c. "Let me take off the monitor belts and help you get into a more comfortable position."
d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
A This statement is belittling the patient's complaints. Support and comfort are necessary.
B Breathing will not decrease the pain.
C It is important to get her into a more comfortable position, but fetal monitoring should continue.
D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation.
11. Why is adequate hydration important when uterine activity occurs before pregnancy is at term?
a. Fluid and electrolyte imbalance can interfere with the activity of the uterine pacemakers.
b. Dehydration may contribute to uterine irritability for some women.
c. Dehydration decreases circulating blood volume, which leads to uterine ischemia.
d. Fluid needs are increased because of increased metabolic activity occurring during contractions.
A Fluid and electrolyte imbalances are not associated with preterm labor.
B Intravenous fluids are ordered according to their expected benefit. Adequate hydration promotes urination and decreased risk for infection.
C The woman has an increase blood volume during pregnancy.
D Fluid needs do not increase due to contractions.
12. In planning for home care of a woman with preterm labor, the nurse needs to address which concern?
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.
A Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed.
B Restricted activity and medication may prevent preterm labor; however, not in all women. Additionally, the plan of care is individualized to meet the needs of each patient.
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.
D Many women will receive home health nurse visits, but care is individualized for each woman.
13. 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.
A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity.
B Inderal would be given to reduce the effects of ritodrine administration.
C Betamethasone has no effect on uterine contractions.
D Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
14. 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.
A It is essential that nurses teach women how to detect the early symptoms of preterm labor.
B Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor.
C Waiting too long to see a health care provider could result in essential medications' failing to be administered. Preterm labor is not necessarily long-term labor.
D Gestational age of 20 to 37 weeks, uterine contractions, and a thinning cervix are all indications of preterm labor.
15. Which nursing action must be initiated first when evidence of prolapsed cord is found?
a. Notify the physician.
b. Apply a scalp electrode.
c. Prepare the mother for an emergency cesarean delivery.
d. Reposition the mother with her hips higher than her head.
A Trying to relieve pressure on the cord should be the first priority.
B Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques.
C Emergency cesarean delivery may be necessary if relief of the cord is not accomplished.
D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed.
16. A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action is to
a. Reposition the woman with her hips slightly elevated.
b. Observe for abnormally high uterine resting tone.
c. Decrease the rate of nonadditive intravenous fluid.
d. Notify the physician promptly and prepare the woman for surgery.
A Repositioning the woman with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
B Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the woman at high risk for uterine rupture.
C The woman is now at high risk for shock. Nonadditive intravenous fluids should be increased.
D Pain between the scapulae may occur when the uterus ruptures, because blood accumulates under the diaphragm. This is an emergency that requires medical intervention.
17. Which action should be initiated to limit hypovolemic shock when uterine inversion occurs?
a. Administer oxygen at 31 L/min by nasal cannula.
b. Administer an oxytocic drug by intravenous push.
c. Monitor fetal heart rate every 5 minutes.
d. Restore circulating blood volume by increasing the intravenous infusion rate.
A Administering oxygen will not prevent hypovolemic shock.
B Oxytocin drugs should not be given until the uterus is repositioned.
C A uterine inversion occurs during the third stage of labor.
D Intravenous fluids are necessary to replace the lost blood volume that occurs in uterine inversion.
18. What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord?
b. Pregnancy at 38 weeks of gestation
c. Presenting part at station -3
d. Meconium-stained amniotic fluid
A Hydramnios puts the woman at high risk for a prolapsed umbilical cord.
B A very small fetus, normally preterm, puts the woman at risk for a prolapsed umbilical cord.
C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture.
D Meconium-stained amniotic fluid shows that the fetus already has been compromised, but it does not increase the chance of a prolapsed cord.
19. The fetus in a breech presentation is often born by cesarean delivery because
a. The buttocks are much larger than the head.
b. Postpartum hemorrhage is more likely if the woman delivers vaginally.
c. Internal rotation cannot occur if the fetus is breech.
d. Compression of the umbilical cord is more likely.
A The head is the largest part of a fetus.
B There is no relationship between breech presentation and postpartum hemorrhage.
C Internal rotation can occur with a breech.
D After the fetal legs and trunk emerge from the woman's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head.
20. An important independent nursing action to promote normal progress in labor is
a. Assessing the fetus
b. Encouraging urination about every 1 to 2 hours
c. Limiting contact with the woman's partner
d. Regulating intravenous fluids
A Assessment of the fetus is an important task, but will not promote normal progression of labor.
B The bladder can reduce room in the woman's pelvis that is needed for fetal descent and can increase her discomfort.
C The woman needs her support system during labor, and contact should not be limited.
D Maintaining hydration is an important task, but it will not promote normal progression of labor.
21. A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is
a. "Back pain is common at this time during pregnancy because you tend to stand with a sway back."
b. "Acetaminophen is acceptable during pregnancy; however, you should not take aspirin."
c. "You should come into the office and let the doctor check you."
d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."
A Back pain can also be a symptom of preterm labor and needs to be assessed.
B The woman needs to be assessed for preterm labor before providing pain relief.
C A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth.
D The woman needs to be assessed for preterm labor before providing pain relief.
22. What is the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline?
a. Fetal heart rate, maternal pulse, and blood pressure
b. Maternal temperature and odor of amniotic fluid
c. Intake and output
d. Maternal blood glucose
A All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure.
B These are important if the membranes have ruptured, but they are not relevant to the medication.
C This is not an important assessment to monitor for side effects of terbutaline.
D This is not an important assessment to monitor for side effects of terbutaline.
23. The nurse should suspect uterine rupture if
a. Fetal tachycardia occurs.
b. The woman becomes dyspneic.
c. Contractions abruptly stop during labor.
d. Labor progresses unusually quickly.
A Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs.
B This is not an early sign of a rupture.
C A large rupture of the uterus will disrupt its ability to contract.
D Contractions will stop with a rupture.
24. Rupture of the amniotic sac before the onset of true labor, regardless of length of gestation is called premature rupture of membranes (PROM). The first priority for the nurse is to determine whether membranes are truly ruptured. Other explanations for this increase in fluid discharge include all except
a. Urinary incontinence
b. Leaking of amniotic fluid
c. Loss of mucous plug
d. An increase in vaginal discharge
A It is not uncommon for patients to mistake urinary incontinence for leakage of amniotic fluid.
B Leaking of amniotic fluid is an indication of PROM.
C Loss of the mucous plug can lead a woman to believe that her membranes have ruptured when they have not.
D Late in pregnancy there may be an increase in vaginal discharge. This may be mistaken for rupture of membranes.
1. The causes of preterm labor are not fully understood although many factors have been associated with early labor. These include (select all that apply)
a. Singleton pregnancy
b. History of cone biopsy
d. Short cervical length
e. Higher level of education
ANS: B, C, D
Correct A history of cone biopsy, smoking, and short cervical length are maternal risk factors for preterm labor. Others include chronic illness, DES exposure as a fetus, uterine abnormalities, obesity, previous preterm labor or birth, number of embryos implanted, preeclampsia, anemia, or infection.
Incorrect Uterine distention caused by multifetal pregnancy or hydramnios are risk factors for preterm labor. Low educational level, low socioeconomic status, little or no prenatal care, poor nutrition, or non-white ethnicity are all demographic risk factors for preterm labor and birth.
1. Nurses need to know that when any woman is admitted to the hospital and is _____ to _____ weeks pregnant, she should receive antenatal glucocorticoids unless she has chorioamnionitis. Because these drugs require a 24-hour period to become effective, timely administration is essential.
All women between 24 and 34 weeks of gestation who are at risk for preterm birth within 7 days should receive treatment with a single course of antenatal glucocorticoids.
2. __________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor.
A dysfunctional labor may result from problems with the powers of labor, the passenger, the passage, the psyche or a combination of these.
3. A nurse is caring for a patient in the active phase of labor. The woman's BOW spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless and cyanotic. Additionally, she becomes hypotensive and tachycardic. The nurse immediately suspects the presence of a(n) _____________.
amniotic fluid embolism
Anaphylactoid syndrome of pregnancy (ASP) is more commonly known as amniotic fluid embolism. This is a rare but devastating complication of pregnancy. It is characterized by the sudden, acute onset of hypoxia, hypotension or cardiac arrest, and coagulopathy. ASP can occur during labor, birth, or within 30 minutes after birth. This clinical presentation is similar to that observed in patients with anaphylactic or septic shock. In both of these conditions, a foreign substance is introduced into the circulation.
1. The nurse has been caring for a primiparous patient who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary. Is this statement true or false?
This is often referred to as the "turtle sign" and is an indication of shoulder dystocia. Delayed or difficult birth of the shoulders may occur if they become impacted above the maternal symphysis pubis. This complication of birth requires immediate intervention because the umbilical cord is compressed and the chest cannot expand within the vagina. Any of several methods may be employed to relieve the impacted shoulders. Shoulder dystocia is unpredictable and although more common in large infants, can occur with a baby of any weight.
2. Infant mortality for late preterm infants (34 to 36 weeks) is three times the rate of mortality for term infants. Is this statement true or false?
This statement is correct. LPI infants may appear full term at birth; however, the appearance of the infant is deceiving. LPI infants have a mortality risk three times that of term infants for death from all causes.
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