c16intracomplications Flashcards
(38 cards)
Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid
ANS: B
The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes.
Which action by the nurse prevents infection in the labor and birth area?
a.
Using clean techniques for all procedures
b.
Keeping underpads and linens as dry as possible
c.
Cleaning secretions from the vaginal area by using a back to front motion
d.
Performing vaginal examinations every hour while the patient is in active labor
ANS: B
Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.
A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2C (99F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates
ANS: C
Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.
A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.
ANS: B
A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.
Which technique is least effective for the patient with persistent occiput posterior position?
a.
Squatting
b.
Lying supine and relaxing
c.
Sitting or kneeling, leaning forward with support
d.
Rocking the pelvis back and forth while on hands and knees
ANS: B
Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.
Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.
ANS: A
Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.
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 patient with ruptured membranes
c.
A primigravida who has requested no analgesia during her labor
d.
A multiparous patient at 39 weeks of gestation who is expecting twins
ANS: D
Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this patient’s uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
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
ANS: A
A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.
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.
palpate the infant’s clavicles.
b.
encourage the parents to hold the infant.
c.
perform a complete newborn assessment.
d.
give supplemental oxygen with a small face mask.
ANS: A
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. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.
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.
“Let me take off the monitor belts and help you get into a more comfortable position.”
c.
“You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain.”
d.
“I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.”
ANS: D
Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation.
Which nursing action should be initiated first when there is evidence of prolapsed cord?
a.
Notify the health care provider.
b.
Apply a scalp electrode.
c.
Prepare the mother for an emergency cesarean birth.
d.
Reposition the mother with her hips higher than her head.
ANS: 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. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete.
A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse’s priority action?
a.
Notify the health care provider promptly.
b.
Observe for abnormally high uterine resting tone.
c.
Decrease the rate of nonadditive intravenous fluid.
d.
Reposition the patient with her hips slightly elevated.
ANS: A
Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of –3 d. Meconium-stained amniotic fluid
ANS: 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. Hydramnios puts the patient at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.
The fetus in a breech presentation is often born by cesarean birth because
a.
the buttocks are much larger than the head.
b.
compression of the umbilical cord is more likely.
c.
internal rotation cannot occur if the fetus is breech.
d.
postpartum hemorrhage is more likely if the patient delivers vaginally.
ANS: B
After the fetal legs and trunk emerge from the patient’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. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.
A patient 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.
“You should come into the office and let the doctor check you.”
b.
“Acetaminophen is acceptable during pregnancy. You should not take aspirin, however.”
c.
“Back pain is common at this time during pregnancy because you tend to stand with a sway back.”
d.
“Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.”
ANS: A
A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The patient needs to be assessed for preterm labor before providing pain relief.
Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)?
a.
Intake and output
b.
Maternal blood glucose level
c.
Internal temperature and odor of amniotic fluid
d.
Fetal heart rate, maternal pulse, and blood pressure
ANS: D
All assessments are important; however, those most relevant to tocolytic therapy 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. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication.
Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.
ANS: D
A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.
Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex.
a.
Augmentation of labor with oxytocin (Pitocin)
b.
AROM
c.
Performing a vaginal exam to denote progress
d.
Preparing the patient for epidural administration as ordered by the physician
ANS: D
The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.
During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request?
a.
Put pressure on the fundus.
b.
Ask the physician if he or she would like you to prepare for a surgical method of birth.
c.
Tell the patient not to push until you prepare the vacuum extraction device for physician.
d.
Reposition the patient to facilitate birth.
ANS: B
In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it may cause additional problems. Vacuum extraction will not help to resolve the birth issue and may lead to further complications. Repositioning of the patient may not be effective to relieve this condition and facilitate birth.
A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test?
a.
Patient must be NPO prior to testing.
b.
Blood work will be drawn every week to help confirm the start of preterm labor.
c.
Patient should refrain from sexual activity prior to testing.
d.
A urine specimen will be collected for testing.
ANS: C
Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.
An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks’ gestation and has two other children at home, ages 3 and 6. The patient’s husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal?
a.
The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient’s next scheduled antepartum visit the following week.
b.
The patient and husband will hire a nanny to act as an additional caregiver for the next month.
c.
The patient will continue to take care of her children at home, taking frequent rest periods.
d.
The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.
ANS: D
A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified timeframe. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the patient to take care of her children at home with rest period because the patient will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.
A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate?
a.
Vaginal birth with vacuum extraction
b.
Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions
c.
Cesarean section
d.
Insertion of Foley catheter into empty bladder to provide more room for fetal descent
ANS: C
The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the patient should be prepped for a cesarean section.
A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care?
a.
Administration of antihypertensive medication
b.
Initiation of CPR and other life support measures
c.
Respiratory treatments with nebulizers
d.
Internal fetal monitoring
ANS: B
Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient with this condition will be hypotensive, not hypertensive.
A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks’ gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient’s request?
a.
There is no way to tell if any complications would arise. Because the patient is not presenting with any problems, the nurse should call the health care provider and inform her or him of the patient’s decision to go home and wait.
b.
Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting.
c.
Tell the patient that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the patient will be sent home.
d.
Tell the patient that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physician’s directions.
ANS: B
The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the patient wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore it is best for the patient to remain in a supervised clinical setting. Indicating that the patient could possibly go home would place the patient at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.
