Perry - Chapter 17 Flashcards
(38 cards)
In planning for home care of a woman with preterm labor, which concern must the nurse address?
a. Nursing assessments will be different from those done in the hospital setting.
b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic effects.
d. Home health care providers will be necessary.
ANS: C
Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many women will receive home health nurse visits, but care is individualized for each woman.
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?
a. Assessing deep tendon reflexes (DTRs)
b. Assessing for chest discomfort and palpitations
c. Assessing for bradycardia
d. Assessing for hypoglycemia
ANS: B
Terbutaline is a 2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. 2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.
ANS: B
Terbutaline is a 2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. 2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.
ANS: D
The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.
A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:
a. Stimulate fetal surfactant production.
b. Reduce maternal and fetal tachycardia associated with ritodrine administration.
c. Suppress uterine contractions.
d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
ANS: A
Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?
a. Estriol is not found in maternal saliva.
b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
c. Fetal fibronectin is present in vaginal secretions.
d. The cervix is effacing and dilated to 2 cm.
ANS: D
Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.
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.
ANS: C
Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. The contraction pattern seen in this woman signifies hypertonic uterine activity. Typically uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.
Which assessment is least likely to be associated with a breech presentation?
a. Meconium-stained amniotic fluid
b. Fetal heart tones heard at or above the maternal umbilicus
c. Preterm labor and birth
d. Post-term gestation
ANS: D
Post-term gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.
A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?
a. Prolonged latent phase c. Arrest of active phase
b. Protracted active phase d. Protracted descent
ANS: C
With an arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
In evaluating the effectiveness of oxytocin induction, the nurse would expect:
a. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.
b. The intensity of contractions to be at least 110 to 130 mm Hg.
c. Labor to progress at least 2 cm/hr dilation.
d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.
ANS: A
The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min.
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, which information would the nurse include?
a. “Because this is a repeat procedure, you are at the lowest risk for complications.”
b. “Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures.”
c. “Because this is your second cesarean birth, you will recover faster.”
d. “You will not need preoperative teaching because this is your second cesarean birth.”
ANS: B
“Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures” is the most appropriate statement. It is not accurate to state that the woman is at the lowest risk for complications. Both maternal and fetal risks are associated with every cesarean section. “Because this is your second cesarean birth, you will recover faster” is not an accurate statement. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed, regardless of whether the client has already had this procedure.
For a woman at 42 weeks of gestation, which finding would require further assessment by the nurse?
a. Fetal heart rate of 116 beats/min
b. Cervix dilated 2 cm and 50% effaced
c. Score of 8 on the biophysical profile
d. One fetal movement noted in 1 hour of assessment by the mother
ANS: D
Self-care in a post-term pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. Normal findings in a 42-week gestation include fetal heart rate of 116 beats/min, cervix dilated 20 cm and 50% effaced, and a score of 8 on the biophysical profile.
A pregnant woman’s amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority?
a. Placing the woman in the knee-chest position
b. Covering the cord in sterile gauze soaked in saline
c. Preparing the woman for a cesarean birth
d. Starting oxygen by face mask
ANS: A
The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.
Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:
a. Enhance uteroplacental perfusion in an aging placenta.
b. Increase amniotic fluid volume.
c. Ripen the cervix in preparation for labor induction.
d. Stimulate the amniotic membranes to rupture.
ANS: C
It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.
A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate?
a. “After the baby is born.”
b. “When we can stabilize your preterm labor and arrange home health visits.”
c. “Whenever the doctor says that it is okay.”
d. “It depends on what kind of insurance coverage you have.”
ANS: B
The 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 woman with preterm labor is multifactorial; the goal is to prevent delivery. In many cases this may be achieved at home. Care of the preterm client is multidisciplinary and multifactorial. Managed care may dictate earlier hospital discharges or a shift from hospital to home care. Insurance coverage may be one factor in the care of clients, but ultimately client safety remains the most important factor.
The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of:
a. Uterine contractions occurring every 8 to 10 minutes.
b. A fetal heart rate (FHR) of 180 with absence of variability.
c. The client’s needing to void.
d. Rupture of the client’s amniotic membranes.
ANS: B
This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The client’s needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client’s membranes have ruptured.
Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance:
a. The terms preterm birth and low birth weight can be used interchangeably.
b. Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
c. Low birth weight is anything below 3.7 pounds.
d. In the United States early in this century, preterm birth accounted for 18% to 20% of all births.
ANS: B
Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 pounds. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency.
With regard to the care management of preterm labor, nurses should be aware that:
a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms.
b. Braxton Hicks contractions often signal the onset of preterm labor.
c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver.
d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
ANS: D
Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.
As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
a. The drugs can be given efficaciously up to the designated beginning of term at 37 weeks.
b. There are no important maternal (as opposed to fetal) contraindications.
c. Its most important function is to afford the opportunity to administer antenatal glucocorticoids.
d. If the client develops pulmonary edema while receiving tocolytics, intravenous (IV) fluids should be given.
ANS: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.
With regard to dysfunctional labor, nurses should be aware that:
a. Women who are underweight are more at risk.
b. Women experiencing precipitous labor are about the only “dysfunctionals” not to be exhausted.
c. Hypertonic uterine dysfunction is more common than hypotonic dysfunction.
d. Abnormal labor patterns are most common in older women.
ANS: B
Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women less than 20 years of age.
The least common cause of long, difficult, or abnormal labor (dystocia) is:
a. Midplane contracture of the pelvis.
b. Compromised bearing-down efforts as a result of pain medication.
c. Disproportion of the pelvis.
d. Low-lying placenta.
ANS: C
The least common cause of dystocia is disproportion of the pelvis.
Nurses should be aware that the induction of labor:
a. Can be achieved by external and internal version techniques.
b. Is also known as a trial of labor (TOL).
c. Is almost always done for medical reasons.
d. Is rated for viability by a Bishop score.
ANS: D
Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons.
While caring for the patient who requires an induction of labor, the nurse should be cognizant that:
a. Ripening the cervix usually results in a decreased success rate for induction.
b. Labor sometimes can be induced with balloon catheters or laminaria tents.
c. Oxytocin is less expensive than prostaglandins and more effective but creates greater health risks.
d. Amniotomy can be used to make the cervix more favorable for labor.
ANS: B
Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe.
With regard to the process of augmentation of labor, the nurse should be aware that it:
a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory.
b. Relies on more invasive methods when oxytocin and amniotomy have failed.
c. Is a modern management term to cover up the negative connotations of forceps-assisted birth.
d. Uses vacuum cups.
ANS: A
Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation.
The nurse providing care to a woman in labor should understand that cesarean birth:
a. Is declining in frequency in the twenty-first century in the United States.
b. Is more likely to be performed for poor women in public hospitals who do not receive the nurse counseling as do wealthier clients.
c. Is performed primarily for the benefit of the fetus.
d. Can be either elected or refused by women as their absolute legal right.
ANS: C
The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. Cesarean births are increasing in the United States in this century. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A 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.
