VN 34 Test 3 Adjusted

Question 1

1. Explain what the “Bishop Score” is.

Answer 1

• One way the health care provider determines cervical readiness is by using the Bishop score.

Question 2

1b. What are the 5 categories, and what do they indicate?

Answer 2

• Five factors are evaluated in the Bishop score:
-cervical consistency
-position
-dilation
-effacement
-fetal station.
• The higher the score the greater the chance that induction will be successful.
• A Bishop score of 6 or less indicates an “unripe” or unfavorable cervix, and labor induction is less likely to be successful

Question 3

2a. What does it mean to “ripen” a cervix?

Answer 3

• A cervical readiness

Question 4

2b. List the mechanical methods of cervical ripening.

Answer 4

• Membrane Stripping:
-The health care provider inserts a gloved finger through the internal cervical os and sweeps the finger 360 degrees to separate the membranes from the lower uterine segment

• Dilation of the cervix by the health care provider using a catheter:
-The tip of the catheter is inserted through the cervix, and the ballon of the catheter is filled with 30 to 80 mL of sterile saline. The inflated ballon rests between the internal cervical os and the amniotic sac.

• Laminaria (or cervical dilators):
-are used to soften and dilate the cervix, usually to induce abortion either therapeutic or elective or to induce labor when the fetus has died in utero. (Made from the root of seaweed)

Question 5

2c. List the pharmacological methods, which one can be administered both PO and vaginally?

Answer 5

• Prostaglandin E2, dinoprostone: is available as a gel or as a vaginal insert.
• Prostaglandin E1, misoprostol,It is administered either orally or vaginally to ripen the cervix

Question 6

3a. Describe an oxytocin induction.

Answer 6

• Intravenous (IV) oxytocin: the posterior pituitary hormone that causes the uterus to contract, is the most common agent used for labor induction

Question 7

3b. What should the nurse do if hyperstimulation occurs?

Answer 7

• Hyperstimulation leads to contractions that occur one after the other without a sufficient rest period in between. This can lead to fetal distress and even uterine rupture.
o Document the fetal heart rate before and after the procedure

Question 8

4a. List the different types of assisted delivery.

Answer 8

• Episiotomy: is a surgical incision made into the perineum to enlarge the posterior part of the vaginal opening just before the baby is born

• Vacuum extraction: in which the birth attendant places a suction cup, made of plastic or soft silicone, on the fetal head and connects it to a handheld suction device

• Forceps are metal instruments with curved, blunted blades (somewhat like large flattened spoons) that are placed around the head of the fetus by the birth attendant to facilitate delivery

Question 9

4b. In which situations would an assisted delivery be necessary?

Answer 9

• The fetus may descend to the pelvic floor without rotating to the anterior position, or the mother may become tired and stop pushing effectively

• Episiotomy:
o The baby’s shoulders are stuck in the birth canal after the head is born (shoulder dystocia).
o The head will not rotate from an occiput posterior position (persistent occiput posterior).
o The fetus is in a breech presentation.
o Instruments (forceps or vacuum) are being used to shorten the second stage of labor.

Question 10

5a. Name the indications for a cesarean delivery.

Answer 10

• History of previous cesarean (or other uterine incision)
• Labor dystocia (failure to progress in labor)
• Nonreassuring fetal status
• Fetal malpresentation
• Placenta previa (placenta covers the cervix)
• Placental abruption (abruptio placentae; placenta separates from the uterus before birth)
• Cephalopelvic disproportion (CPD; this is when the fetal head is too large to fit through the pelvis)
• Active vaginal herpes lesions
• Prolapse of the umbilical cord
• Ruptured uterus
• Premature delivery of the fetus
• Maternal diabetes
• Preeclampsia
• Erythroblastosis fetalis
• Fetal malformations (such as spina bifida)

Question 11

5b. In which step of a cesarean would the LVN not participate?

Answer 11

• Postoperative care in the PACU.
o We may assume care of the woman during the postoperative phase, after she has sufficiently recovered from anesthesia

Question 12

6a. When a client is having a planned cesarean section, what must the patient sign?

Answer 12

• Consent form document

Question 13

6b. Can the paper work be signed ahead of time?

Answer 13

• Yes

Question 14

7. Describe how the nurse can support her patient and the patient’s family in the event of an unplanned cesarean.

Answer 14

• Include the family in any explanations
• Through therapeutic communication, providing information, and a reassuring touch.
• Include the woman in conversations instead of talking to other staff as though the woman is not present.
• Encourage the woman to rest in-between contractions. During these rest periods, avoid conversations that are not related to the delivery
• A quiet room in-between contractions can help the woman rest and therefore better cope during the intervention or contractions.
• Explain procedures as you are doing them. Use short, nontechnical sentences. The woman’s anxiety may be elevated and she may not be able to process lengthy or detailed explanations. (Repeat info as needed)
• Explain what sensations she can expect to experience and what procedure to expect next.
• Be empathic. Acknowledge her feelings and let her know that these feelings are normal
• Considering the situation with which she must cope.

Question 15

8. What is a VBAC and when is it contraindicated?

Answer 15

• Vaginal birth after cesarean

• Contraindicated:
o When a woman has a classical uterine incision from a previous cesarean delivery
o Placenta previa
o History of previous uterine rupture
o Lack of facilities or equipment to perform an immediate emergency cesarean.

Question 16

9a. Describe the signs and symptoms of a uterine rupture.

Answer 16

• Dramatic onset of fetal bradycardia or deep variable decelerations
• Reports by the woman of a “popping” sensation in her abdomen
• Excessive maternal pain (can be referred pain, such as to the chest)
• Unrelenting uterine contraction followed by a disorganized uterine pattern
• Increased fetal station felt upon vaginal examination (e.g., station is now −3 when it has been −1)
• Vaginal bleeding or increased bloody show
• Easily palpable fetal parts through the abdominal wall
• Signs of maternal shock

Question 17

9b. In the event of uterine rupture, what is the treatment of choice?

Answer 17

• Immediate cesarean delivery

Question 18

10a. List the causes of labor dysfunction.

Answer 18

• Uterine Dysfunction
Hypotonic (most common).- uterine contractions that lack thequantity or strength to dilate the cervix, regardless of the regularity of the contraction pattern

Hypertonic present two different ways
- The most common is frequent, but ineffective, contractions
- Increased frequency and intensity of uterine contractions (precipitous labor)

• Cephalopelvic Disproportion:
o In this situation, the diameters of the fetal head are too large to pass through the birth canal. CPD can be due to an enlarged fetal head, such as in fetal macrosomia or hydrocephalus, or it can result from a small maternal pelvis.

• Fetal Malposition
o Fetal malposition can cause prolonged labor. When the back of the fetal head is toward the posterior portion of the maternal pelvis, the position is occiput posterior

Question 19

10b. What are the treatment for hypertonic and hypotonic labor?

Answer 19

• Treatment for this cause of hypertonic labor is to decrease or shut off the oxytocin infusion.
• Hypotonic: Augmentation w/ oxytocin

Question 20

11. List the options of interventions for a safe delivery of a client whom presents with a breech presentation and for a transverse lie.

Answer 20

• Breech Presentations:
o Most health care providers prefer to do a cesarean birth without labo or attempting a vaginal delivery
o External cephalon version (manipulating the position of the fetus while in utero)

• Transverse lie (shoulder presentation), there are two options.
o The health care provider will either use external cephalic version to try to turn the fetus to a cephalic presentation or deliver the fetus by cesarean.
o If a transverse lie persists, the fetus cannot deliver vaginally

Question 21

12a. What is the priority for the woman with premature rupture of membranes?

Answer 21

• PROM- refers to spontaneous rupture of the amniotic sac before the onset of labor
o Monitor for infection

Question 22

12b. Describe the management of preterm PROM, including fetal surveillance.

Answer 22

• If there is no infection, the health care provider may choose expectant management (“wait and see” method). The goal is to allow the fetus time to mature and achieve delivery before the woman or her fetus becomes infected. Prophylactic antibiotics (usually ampicillin and erythromycin) may be ordered for preterm PROM. The usual practice is to administer 7 days of antibiotic therapy.
• Preterm PROM between 24 and 34 weeks, intramuscular corticosteroids are given to the mother to reduce the risk of neonatal respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis
• Fetal surveillance is done at least daily. Generally, the woman performs kick counts after every meal. Daily nonstress tests may also be ordered. Frequent ultrasound examinations to measure the amount of amniotic fluid and fetal growth are also done.

Question 23

13. What are the guidelines for the patient who is not in true labor?

Answer 23

• After the initial assessment by the health care provider, the woman may be instructed to
  walk for an hour or two. Then, a vaginal examination is repeated to determine any
  cervical changes

-If the contractions become stronger, more regular, or if other signs of true labor occur
such as rupture of membranes (“bag of waters breaks”) or presence of bloody show
(mucous vaginal discharge that is pink or brown tinged which occurs as the blood vessels
in the cervix start to rupture as effacement and dilation are beginning)

Question 24

14.What is the significance of a fetal fibronectin test and cervical length?

Answer 24

• The most frequent examinations used to diagnose PTL include evaluation of
-contraction frequency
-fetal fibronectin test
-measurement of cervical length

o Short cervical length with a positive fetal fibronectin test (meaning there was fetal fibronectin in the vaginal secretions) indicates that the woman has an increased chance of delivering prematurely

Question 25

15. What are the signs and symptoms and treatment for preterm labor?

Answer 25

Sign & symptoms
• Cervix has dilated to greater than 3 cm.
• Uterine contractions, which may be painless
• Pelvic pressure
• Menstrual-like cramps
• Vaginal pain
• Low, dull backache
• Vaginal discharge and bleeding.
• The membranes may be intact or ruptured

Treatment
• The traditional treatment of bed rest is no longer recommended because of the increased risk of thromboembolism with prolonged bed rest.
• The health care provider must decide if tocolytics are appropriate.
o Although the medication may not prevent preterm birth, tocolytics often buy enough time to allow for corticosteroid injections to help mature the fetal lungs, treatment of group B streptococcal infections, if present, or to allow transfer to a facility with a higher level of neonatal intensive care.

Question 26

16a. Describe the potential side effects when a patient is on Magnesium Sulfate or Terbutaline, while baby is still inside.

Answer 26

Magnesium Sulfate
• At therapeutic levels: Flushing, feelings of warmth, diaphoresis, lethargy, pulmonary edema
• At toxic levels: Respiratory depression, tetany, paralysis, profound hypotension, cardiac arrest

Terbutaline
o Monitor serum potassium and glucose level
o Report if adnormal level

Question 27

16b. Describe potential side effects on mom when on Magnesium Sulfate after baby has been born.

Answer 27

• At therapeutic levels: Slight decrease in baseline fetal heart rate level and variability
• At toxic levels: Nonreactive NST; decreased fetal breathing movements

Question 28

16c. What condition necessitates mom to be on magnesium Sulfate after delivery?

Answer 28

• Prevention & treatment of eclampsia seizures or postpartum preeclampsia

Question 29

17. What are some very important actions of the nurse in the postpartum period of an intrauterine fetal death, also known as fetal demise?

Answer 29

• Allow the woman and her family space to comfort one another, but do not avoid her.
• Offer to call a pastor or other spiritual leader.
• Be sure to determine whether the woman would like any religious sacraments or rituals
• Encourage her to hold and name her baby if she is able. Avoid statements such as “It wasn’t the baby’s time to be born” which are nontherapeutic and hurtful to the grieving parent.
• Take pictures as dictated by institutional policy. Pictures are usually taken even if the woman refuses them. The chaplain or social worker may keep the pictures on file for a year or more. Inform the woman that she can change her mind and come get the pictures at any time

Question 30

18a. Describe what a shoulder dystocia is.

Answer 30

• In shoulder dystocia, the fetal head delivers, but the shoulders become stuck in the bony pelvis, preventing delivery of the body.
• The fetus can suffer permanent brain damage because their chest cannot expand, limiting the first breath

Question 31

18b. What are the signs, symptoms, and the treatment for shoulder dystocia?

Answer 31

• The “turtle sign” is the classic sign that alerts the birth attendant to the probability of shoulder dystocia. The fetal head delivers, but then retracts similar to a turtle
o The birth attendant is unable to deliver the infant using the normal maneuvers including gentle downward pressure on the fetal head in an attempt to deliver the anterior shoulder.

Treatment:
• McRoberts maneuver. This intervention is frequently successful and is often tried first.
o McRoberts requires the assistance of two individuals.
o Two nurses are ideal; however, a support person or a technician can serve as the second assistant.
o With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman’s shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases

• Suprapubic pressure
o One nurse can use a fist to apply suprapubic pressure. This will sometimes dislodge the impacted shoulder.

• Zavanelli Maneuver
o The birth attendant can try other maneuvers, such as placing a hand in the vagina and attempting to push one of the shoulders in a clockwise or counterclockwise motion.
o Intentionally fracturing a clavicle may help dislodge the fetus. In some cases, the fetal head may be pushed back in the birth canal and an emergency cesarean delivery performed

Question 32

19. Describe the treatment for an umbilical cord prolapse.

Answer 32

• Immediate cesarean delivery is the treatment of choice to save the fetus’s life

Question 33

20. Name the signs of a uterine rupture.

Answer 33

• A nonreassuring fetal heart rate patten
• Pain-abdomen, shoulder, back
• Falling BP
• Rising pulse
• Bleeding
• Higher fetal station
• May or may not be changes in contraction pattern