Chapter 32

Question 1

1. In planning for home care of a woman with preterm labor, which concern should the nurse need to address?
   a. Nursing assessments are different from those performed in the hospital setting.
   b. Restricted activity and medications are necessary to prevent a recurrence of preterm labor.
   c. Prolonged bed rest may cause negative physiologic effects.
   d. Home health care providers are necessary.

Answer 1

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 differ somewhat from those performed in the acute care setting, but this concern does not need to be addressed. Restricted activity and medications may prevent preterm labor but not in all women. In addition, the plan of care is individualized to meet the needs of each client. Many women receive home health nurse visits, but care is individualized for each woman.

Question 2

2. Which nursing intervention is paramount when providing care to a client with preterm labor who has received terbutaline?
   a. Assess deep tendon reflexes (DTRs).
   b. Assess for dyspnea and crackles.
   c. Assess for bradycardia.
   d. Assess for hypoglycemia.

Answer 2

ANS: B
Terbutaline is a beta2-adrenergic agonist that affects the mother’s cardiopulmonary and metabolic systems. Signs of cardiopulmonary decompensation include adventitious breath sounds and dyspnea. An assessment for dyspnea and crackles is important for the nurse to perform if the woman is taking magnesium sulfate. Assessing DTRs does not address the possible respiratory side effects of using terbutaline. Since terbutaline is a beta2-adrenergic agonist, it can lead to hyperglycemia, not hypoglycemia. Beta2-adrenergic agonist drugs cause tachycardia, not bradycardia.

Question 3

3. In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, which finding alerts the nurse to possible side effects?
   a. Urine output of 160 ml in 4 hours
   b. DTRs 2+ and no clonus
   c. Respiratory rate (RR) of 16 breaths per minute
   d. Serum magnesium level of 10 mg/dl

Answer 3

ANS: D
The therapeutic range for magnesium sulfate management is 4 to 7.5 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, DTRs of 2+, and a RR of 16 breaths per minute are all normal findings.

Question 4

4. A woman in preterm labor at 30 weeks of gestation receives two 12-mg intramuscular (IM) doses of betamethasone. What is the purpose of this pharmacologic intervention?
   a. To stimulate fetal surfactant production
   b. To reduce maternal and fetal tachycardia associated with ritodrine administration
   c. To suppress uterine contractions
   d. To maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy

Answer 4

ANS: A
Antenatal glucocorticoids administered as IM injections to the mother accelerate fetal lung maturity. Propranolol (Inderal) is given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate is given to reverse the respiratory depressive effects of magnesium sulfate therapy.

Question 5

5. A primigravida at 40 weeks of gestation is having uterine contractions every to 2 minutes and states 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 precipitous labor.

Answer 5

ANS: C
The contraction pattern observed 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. Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, are often 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. Precipitous labor is one that lasts less than 3 hours from the onset of contractions until time of birth.

Question 6

6. A woman is having her first child. She has been in labor for 15 hours. A vaginal examination performed 2 hours earlier revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part of the fetus was at station 0; however, another vaginal examination performed 5 minutes ago indicated no changes. What abnormal labor pattern is associated with this description?
   a. Prolonged latent phase
   b. Protracted active phase
   c. Secondary arrest
   d. Protracted descent

Answer 6

ANS: C
With a secondary arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, indicating an arrest of labor. In the nulliparous woman, a prolonged latent phase typically lasts longer than 20 hours. A protracted active phase, the first or second stage of labor, is prolonged (slow dilation). With a protracted descent, the fetus fails to descend at an anticipated rate during the deceleration phase and second stage of labor.

Question 7

7. Prostaglandin gel has been ordered for a pregnant woman at 43 weeks of gestation. What is the primary purpose of prostaglandin administration?
   a. To enhance uteroplacental perfusion in an aging placenta
   b. To increase amniotic fluid volume
   c. To ripen the cervix in preparation for labor induction
   d. To stimulate the amniotic membranes to rupture

Answer 7

ANS: C
Preparations of prostaglandin E1 and E2 are effective when used before labor induction to ripen (i.e., soften and thin) the cervix. Uteroplacental perfusion is not altered by the use of prostaglandins. The insertion of prostaglandin gel has no effect on the level of amniotic fluid. In some cases, women will spontaneously begin laboring after the administration of prostaglandins, thereby eliminating the need for oxytocin. It is not common for a woman’s membranes to rupture as a result of prostaglandin use.

Question 8

8. 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 might 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 your physician says that it is okay.”
   d. “It depends on what kind of insurance coverage you have.”

Answer 8

ANS: B
This client’s 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 client with preterm labor is multidisciplinary and multifactorial; the goal is to prevent delivery. In many cases, this goal may be achieved at home. Managed care may dictate an earlier hospital discharge or a shift from hospital to home care. Insurance coverage may be one factor in client care, but ultimately, client safety remains the most important factor.

Question 9

9. The obstetric provider has informed the nurse that she will be performing an amniotomy on the client to induce labor. What is the nurse’s highest priority intervention after the amniotomy is performed?
   a. Applying clean linens under the woman
   b. Taking the client’s vital signs
   c. Performing a vaginal examination
   d. Assessing the fetal heart rate (FHR)

Answer 9

ANS: D
The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse. Providing comfort measures, such as clean linens, for the client is important but not the priority immediately after an amniotomy. The woman’s temperature should be checked every 2 hours after the rupture of membranes but not the priority immediately after an amniotomy. The woman would have had a vaginal examination during the procedure. Unless cord prolapse is suspected, another vaginal examination is not warranted. Additionally, FHR assessment provides clinical cues to a prolapsed cord.

Question 10

10. The nurse who elects to work in the specialty of obstetric care must have the ability to distinguish between preterm birth, preterm labor, and low birth weight. Which statement regarding this terminology is correct?
    a. 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 gestation.
    c. Low birth weight is a newborn who weighs below 3.7 pounds.
    d. Preterm birth rate in the United States continues to increase.

Answer 10

ANS: B
Before 20 weeks of gestation, the fetus is not viable (miscarriage); after 37 weeks, the fetus can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (before 37 weeks), regardless of the newborn’s weight; low birth weight describes only the infant’s weight at the time of birth (2500 g or less), whenever it occurs. Low birth weight is anything below 2500 g or approximately 5 1/2 pounds. In 2011, the preterm birth rate in the United States was 11.7 %; it has dropped every year since 2008.

Question 11

11. The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is the most important for the nurse to understand and share with the client?
    a. Because all women must be considered at risk for preterm labor and prediction is so variable, teaching pregnant women the symptoms of preterm labor 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. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

Answer 11

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 essential medications failing to be administered. Preterm labor is not necessarily long-term labor.

Question 12

12. Which statement related to cephalopelvic disproportion (CPD) is the least accurate?
    a. CPD can be related to either fetal size or fetal position.
    b. The fetus cannot be born vaginally.
    c. CPD can be accurately predicted.
    d. Causes of CPD may have maternal or fetal origins.

Answer 12

ANS: C
Unfortunately, accurately predicting CPD is not possible. Although CPD is often related to excessive fetal size (macrosomia), malposition of the fetal presenting part is the problem in many cases, not true CPD. When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. CPD may be related to either fetal origins such as macrosomia or malposition or maternal origins such as a too small or malformed pelvis.

Question 13

13. Which statement related to the induction of labor is most accurate?
    a. Can be achieved by external and internal version techniques
    b. Is also known as a trial of labor (TOL)
    c. Is almost always performed for medical reasons
    d. Is rated for viability by a Bishop score

Answer 13

ANS: D
Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers or 5 or higher for veterans. Version is the turning of the fetus to a better position by a physician for an easier or safer birth. A TOL 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 not done for medical reasons.

Question 14

14. A number of methods can be used for inducing labor. Which cervical ripening method falls under the category of mechanical or physical?
    a. Prostaglandins are used to soften and thin the cervix.
    b. Labor can sometimes be induced with balloon catheters or laminaria tents.
    c. Oxytocin is less expensive and more effective than prostaglandins but creates greater health risks.
    d. Amniotomy can be used to make the cervix more favorable for labor.

Answer 14

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.

Question 15

15. Which description most accurately describes the augmentation of labor?
    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

Answer 15

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 more gentle, noninvasive methods. Forceps-assisted births are less common than in the past and not considered a method of augmentation. A vacuum-assisted delivery occurs during childbirth if the mother is too exhausted to push. Vacuum extraction is not considered an augmentation methodology.

Question 16

16. The exact cause of preterm labor is unknown but believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Which type of infection has not been linked to preterm birth?
    a. Viral
    b. Periodontal
    c. Cervical
    d. Urinary tract

Answer 16

ANS: A
Infections that increase the risk of preterm labor and birth are bacterial and include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, early, continual, and comprehensive participation by the client in her prenatal care is important. Recent 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 periodontal infections.

Question 17

17. The nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching?
    a. Report a temperature higher than 40 C.
    b. Tampons are safe to use to absorb the leaking amniotic fluid.
    c. Do not engage in sexual activity.
    d. Taking frequent tub baths is safe.

Answer 17

ANS: C
Sexual activity should be avoided because it may induce preterm labor. A temperature higher than 38 C should be reported. To prevent the risk of infection, tub baths should be avoided and nothing should be inserted into the vagina. Further, foul-smelling vaginal fluid, which may be a sign of infection, should be reported.

Question 18

18. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which 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.

Answer 18

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.

Question 19

19. 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. Postterm gestation

Answer 19

ANS: D
Postterm gestation is not likely to occur with a breech presentation. The presence of meconium in a breech presentation may be a result of 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.

Question 20

20. A pregnant woman’s amniotic membranes have ruptured. A prolapsed umbilical cord is suspected. What intervention would be the nurse’s highest 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

Answer 20

ANS: A
The woman is assisted into a 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.

Question 21

21. What is the primary purpose for the use of tocolytic therapy to suppress uterine activity?
    a. Drugs can be efficaciously administered up to the designated beginning of term at 37 weeks gestation.
    b. Tocolytic therapy has no important maternal (as opposed to fetal) contraindications.
    c. The most important function of tocolytic therapy is to provide the opportunity to administer antenatal glucocorticoids.
    d. If the client develops pulmonary edema while receiving tocolytic therapy, then intravenous (IV) fluids should be given.

Answer 21

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

Question 22

22. When would an internal version be indicated to manipulate the fetus into a vertex position?
    a. Fetus from a breech to a cephalic presentation before labor begins
    b. Fetus from a transverse lie to a longitudinal lie before a 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 a vaginal birth

Answer 22

ANS: D
Internal version is used only during a vaginal birth to manipulate the second twin into a presentation that allows it to be vaginally born. For internal version to occur, the cervix needs to be completely dilated.

Question 23

23. A client at 39 weeks of gestation has been admitted for an external version. Which intervention would the nurse anticipate the provider to order?
    a. Tocolytic drug
    b. Contraction stress test (CST)
    c. Local anesthetic
    d. Foley catheter

Answer 23

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

Question 24

24. What is a maternal indication for the use of vacuum-assisted birth?
    a. Wide pelvic outlet
    b. Maternal exhaustion
    c. History of rapid deliveries
    d. Failure to progress past station 0

Answer 24

ANS: B
A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client 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-assisted birth.

Question 25

25. Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?
    a. Assessing the infant for signs of trauma
    b. Administering prophylactic antibiotic agents to the infant
    c. Applying a cold pack to the infant’s scalp
    d. Measuring the circumference of the infant’s head

Answer 25

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 place the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.

Question 26

1. The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues alert the nurse that the woman is experiencing uterine hyperstimulation? (Select all that apply.)
   a. Uterine contractions lasting 2 minutes in frequency
   b. Uterine contractions lasting >90 seconds and occurring 20 mm Hg
   e. Increased uterine activity accompanied by a nonreassuring FHR and pattern

Answer 26

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

Question 27

2. What are the complications and risks associated with cesarean births? (Select all that apply.)
   a. Pulmonary edema
   b. Wound dehiscence
   c. Hemorrhage
   d. Urinary tract infections
   e. Fetal injuries

Answer 27

ANS: A, B, C, D, E
Pulmonary edema, wound dehiscence, hemorrhage, urinary tract infections, and fetal injuries are possible complications and risks associated with cesarean births.

Question 28

3. Women who are obese are at risk for several complications during pregnancy and birth. Which of these would the nurse anticipate with an obese client? (Select all that apply.)
   a. Thromboembolism
   b. Cesarean birth
   c. Wound infection
   d. Breech presentation
   e. Hypertension

Answer 28

ANS: A, B, C, E
A breech presentation is not a complication of pregnancy or birth for the client who is obese. Venous thromboembolism is a known risk for obese women. Therefore, the use of thromboembolism-deterrent (TED) hose and sequential compression devices may help decrease the chance for clot formation. Women should also be encouraged to ambulate as soon as possible. In addition to having an increased risk for complications with a cesarean birth, in general, obese women are also more likely to require an emergency cesarean birth. Many obese women have a pannus (i.e., large roll of abdominal fat) that overlies a lower transverse incision made just above the pubic area. The pannus causes the area to remain moist, which encourages the development of infection. Obese women are more likely to begin pregnancy with comorbidities such as hypertension and type 2 diabetes.

Question 29

4. The 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 clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (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. Postterm pregnancy
   e. Fetal death

Answer 29

ANS: A, C, D, E
The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (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 of completed gestation.

Question 30

5. Indications for a primary cesarean birth are often nonrecurring. Therefore, a woman who has had a cesarean birth with a low transverse scar may be a candidate for vaginal birth after cesarean (VBAC). Which clients would be less likely to have a successful VBAC? (Select all that apply.)
   a. Lengthy interpregnancy interval
   b. African-American race
   c. Delivery at a rural hospital
   d. Estimated fetal weight 30)

Answer 30

ANS: B, C, E
Indications for a low success rate for a VBAC delivery include a short interpregnancy interval, non-Caucasian race, gestational age longer than 40 weeks, maternal obesity, preeclampsia, fetal weight greater than 4000 g, and delivery at a rural or private hospital.

Question 31

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.

Answer 31

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. Irregular, mild contractions that do not cause cervical change are not considered a threat. 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. 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.

Question 32

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

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.”

Answer 32

Ans: B
The statement in B is most appropriate. The statements in A, C, and D are not accurate. Maternal and fetal risks are associated with every cesarean section. 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.

Question 33

For a woman at 42 weeks of gestation, which finding requires more 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

Answer 33

Ans: D
Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If she feels fewer than four movements, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. The findings described in the other choices are normal at 42 weeks of gestation.

Question 34

A pregnant woman’s amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse’s top priority?

a. Place the woman in the knee-chest position.
b. Cover the cord in a sterile towel saturated with warm normal saline.
c. Prepare the woman for a cesarean birth.
d. Start oxygen by face mask.

Answer 34

Ans: A
The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Relieving pressure on the cord is the nursing priority. The nurse may also use her gloved hand or two fingers to lift the presenting part off the cord. If the cord is protruding from the vagina it may be covered with a sterile towel soaked in saline. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete.

Question 35

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse 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 client needing to void.
d. Rupture of the client’s amniotic membranes.

Answer 35

Ans: B
A fetal heart rate (FHR) of 180 with absence of variability is nonreassuring; the oxytocin should be immediately discontinued and the physician should be notified. The oxytocin should also be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. The client needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. The oxytocin does not need to be discontinued when the membranes rupture, but the physician should be notified.

Question 36

With regard 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 pulmonary edema develops while the client is receiving tocolytics, IV fluids should be given.

Answer 36

Ans: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development might 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.

Question 37

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 women experiencing dysfunctional labor who are not exhausted.
c. Hypertonic uterine dysfunction is more common than hypotonic dysfunction.
d. Abnormal labor patterns are most common in older women.

Answer 37

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 younger than 20 years.

Question 38

A nurse providing care to a woman in labor should be aware that cesarean birth:

a. Is declining in frequency in the United States.
b. Is more likely to be performed in the poor in public hospitals who do not receive the nurse counseling that wealthier clients do.
c. Is performed primarily for the benefit of the fetus.
d. Can be either elected or refused by women as their absolute legal right.

Answer 38

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. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A woman’s 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.

Question 39

Which statement is most likely to be associated with a breech presentation?

a. Least common malpresentation
b. Descent rapid
c. Diagnosis by ultrasound only
d. High rate of neuromuscular disorders

Answer 39

Ans: D
Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. Breech is the most common malpresentation, affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as the fetal head. Diagnosis is made by abdominal palpation and vaginal examination, and is confirmed by ultrasound.

Question 40

Which factors would lead to an increased likelihood of uterine rupture? (Select all that apply.)

a. Preterm singleton pregnancy
b. G3P3 with all vaginal deliveries
c. Short interval between pregnancies
d. Patient receiving a trial of labor (TOL) following a VBAC delivery
e. Patient who had a primary caesarean section with a classic incision

Answer 40

Ans: C, D, E
The shorter the interval between pregnancies/deliveries, the higher the risk of uterine rupture. A patient who is having a TOL following a VBAC and a patient who has had a C section with a classic incision into the uterus are at increased risk for uterine rupture. A pregnant woman with a singleton pregnancy (one fetus), even if preterm, is not considered to be at increased risk for uterine rupture; nor is a multipara who has delivered all her infants vaginally.