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Questions and Answers
A primiparous woman in the latent phase of labor is experiencing frequent, intense contractions but her cervix is not dilating. What is the MOST appropriate nursing intervention?
A primiparous woman in the latent phase of labor is experiencing frequent, intense contractions but her cervix is not dilating. What is the MOST appropriate nursing intervention?
- Provide pain relief measures and promote rest. (correct)
- Administer oxytocin to augment labor.
- Prepare the patient for an emergency cesarean birth.
- Encourage ambulation to promote cervical dilation.
During labor, a fetal heart rate tracing shows repetitive late decelerations. The mother is hypotensive. Which intervention should the nurse perform FIRST?
During labor, a fetal heart rate tracing shows repetitive late decelerations. The mother is hypotensive. Which intervention should the nurse perform FIRST?
- Increase the rate of oxytocin infusion.
- Prepare for an immediate cesarean birth.
- Administer oxygen via face mask.
- Reposition the mother to a lateral position. (correct)
Following an amniotomy, the nurse's priority assessment should be:
Following an amniotomy, the nurse's priority assessment should be:
- Uterine contraction frequency.
- Maternal temperature.
- Cervical dilation.
- Fetal heart rate. (correct)
A woman is in active labor when the nurse observes the umbilical cord protruding from the vagina. What is the initial nursing action?
A woman is in active labor when the nurse observes the umbilical cord protruding from the vagina. What is the initial nursing action?
A laboring woman with a history of a prior cesarean birth is requesting a vaginal birth after cesarean (VBAC). Which factor would be a contraindication to VBAC?
A laboring woman with a history of a prior cesarean birth is requesting a vaginal birth after cesarean (VBAC). Which factor would be a contraindication to VBAC?
What is the MOST important nursing intervention during an oxytocin infusion for labor induction?
What is the MOST important nursing intervention during an oxytocin infusion for labor induction?
After delivery, a multiparous woman experiences profuse vaginal bleeding and a boggy uterus. Which medication should the nurse anticipate administering FIRST?
After delivery, a multiparous woman experiences profuse vaginal bleeding and a boggy uterus. Which medication should the nurse anticipate administering FIRST?
A patient experiencing shoulder dystocia during delivery. What maneuvers should the nurse prepare to assist with?
A patient experiencing shoulder dystocia during delivery. What maneuvers should the nurse prepare to assist with?
A newborn delivered via vacuum extraction has a cephalohematoma. What information is MOST important for the nurse to include in the parents' discharge teaching?
A newborn delivered via vacuum extraction has a cephalohematoma. What information is MOST important for the nurse to include in the parents' discharge teaching?
Which of the following is a sign of amniotic fluid embolism (AFE)?
Which of the following is a sign of amniotic fluid embolism (AFE)?
A woman at 41 weeks gestation is admitted for induction of labor. Prior to initiating oxytocin, the nurse assesses the cervix using the Bishop score. Which Bishop score finding is MOST favorable for a successful induction?
A woman at 41 weeks gestation is admitted for induction of labor. Prior to initiating oxytocin, the nurse assesses the cervix using the Bishop score. Which Bishop score finding is MOST favorable for a successful induction?
During the second stage of labor, a woman with an epidural is having difficulty pushing effectively. Which nursing intervention is MOST helpful?
During the second stage of labor, a woman with an epidural is having difficulty pushing effectively. Which nursing intervention is MOST helpful?
A patient is diagnosed with hypotonic uterine dysfunction. Which of the following characteristics describes this condition?
A patient is diagnosed with hypotonic uterine dysfunction. Which of the following characteristics describes this condition?
What is the primary purpose of amnioinfusion during labor?
What is the primary purpose of amnioinfusion during labor?
Which of the following findings would indicate uterine rupture during labor?
Which of the following findings would indicate uterine rupture during labor?
A patient at 39 weeks gestation is in active labor. The fetal heart rate tracing shows a Category III pattern. What is the MOST appropriate nursing intervention?
A patient at 39 weeks gestation is in active labor. The fetal heart rate tracing shows a Category III pattern. What is the MOST appropriate nursing intervention?
Which of the following is a contraindication for external cephalic version (ECV)?
Which of the following is a contraindication for external cephalic version (ECV)?
Following a forceps-assisted vaginal delivery, the nurse should prioritize assessment for:
Following a forceps-assisted vaginal delivery, the nurse should prioritize assessment for:
A patient is receiving oxytocin for labor augmentation. The nurse observes contractions lasting 90 seconds occurring every 2 minutes. What is the MOST appropriate action?
A patient is receiving oxytocin for labor augmentation. The nurse observes contractions lasting 90 seconds occurring every 2 minutes. What is the MOST appropriate action?
A patient is admitted in active labor with a known history of genital herpes. Which intervention is MOST important?
A patient is admitted in active labor with a known history of genital herpes. Which intervention is MOST important?
Which of the following is a risk factor for umbilical cord prolapse?
Which of the following is a risk factor for umbilical cord prolapse?
After a vaginal delivery, a patient reports severe perineal pain and rectal pressure. The nurse suspects a hematoma. What is the MOST appropriate initial nursing intervention?
After a vaginal delivery, a patient reports severe perineal pain and rectal pressure. The nurse suspects a hematoma. What is the MOST appropriate initial nursing intervention?
A patient is in labor, and the nurse notes meconium-stained amniotic fluid. Which action is MOST important?
A patient is in labor, and the nurse notes meconium-stained amniotic fluid. Which action is MOST important?
Which of the following is a sign of maternal soft tissue obstruction during labor?
Which of the following is a sign of maternal soft tissue obstruction during labor?
A patient is scheduled for an external cephalic version (ECV). Which medication should the nurse anticipate being administered prior to the procedure?
A patient is scheduled for an external cephalic version (ECV). Which medication should the nurse anticipate being administered prior to the procedure?
What is the primary indication for performing an internal version?
What is the primary indication for performing an internal version?
A patient is undergoing induction of labor with oxytocin. The fetal heart rate shows recurrent late decelerations. What is the nurse's priority action?
A patient is undergoing induction of labor with oxytocin. The fetal heart rate shows recurrent late decelerations. What is the nurse's priority action?
Which of the following is a risk associated with vacuum extraction?
Which of the following is a risk associated with vacuum extraction?
A laboring patient suddenly reports sharp, severe abdominal pain and becomes diaphoretic. The fetal heart rate tracing shows prolonged bradycardia. What complication is MOST likely?
A laboring patient suddenly reports sharp, severe abdominal pain and becomes diaphoretic. The fetal heart rate tracing shows prolonged bradycardia. What complication is MOST likely?
A patient is in the second stage of labor and reports a strong urge to push, but the nurse notes that the cervix is only 6 cm dilated. What is the MOST appropriate nursing action?
A patient is in the second stage of labor and reports a strong urge to push, but the nurse notes that the cervix is only 6 cm dilated. What is the MOST appropriate nursing action?
A patient is diagnosed with placenta previa at 32 weeks gestation. What activity should the nurse instruct the patient to avoid?
A patient is diagnosed with placenta previa at 32 weeks gestation. What activity should the nurse instruct the patient to avoid?
A patient in labor has a history of opioid abuse. What is the MOST important nursing consideration regarding pain management?
A patient in labor has a history of opioid abuse. What is the MOST important nursing consideration regarding pain management?
Which of the following is an indication for a cesarean birth?
Which of the following is an indication for a cesarean birth?
A newborn is noted to have petechiae over the presenting part after a rapid vaginal delivery. What is the MOST appropriate nursing intervention?
A newborn is noted to have petechiae over the presenting part after a rapid vaginal delivery. What is the MOST appropriate nursing intervention?
A primigravida client at 40 weeks' gestation is being induced with oxytocin due to oligohydramnios. After several hours, the client reports a persistent headache and blurred vision. What complication should the nurse suspect?
A primigravida client at 40 weeks' gestation is being induced with oxytocin due to oligohydramnios. After several hours, the client reports a persistent headache and blurred vision. What complication should the nurse suspect?
During the immediate postpartum period, a client who had a forceps-assisted delivery is suspected of having a vaginal hematoma. Which of the following findings would support this suspicion?
During the immediate postpartum period, a client who had a forceps-assisted delivery is suspected of having a vaginal hematoma. Which of the following findings would support this suspicion?
A patient is diagnosed with hypertonic uterine dysfunction in early labor. Which intervention is MOST appropriate to promote a more effective labor pattern?
A patient is diagnosed with hypertonic uterine dysfunction in early labor. Which intervention is MOST appropriate to promote a more effective labor pattern?
A patient at 38 weeks’ gestation is admitted in active labor. Upon assessment, the nurse determines that the fetus is in a breech presentation. What is the nursing priority?
A patient at 38 weeks’ gestation is admitted in active labor. Upon assessment, the nurse determines that the fetus is in a breech presentation. What is the nursing priority?
Which finding would lead the nurse to suspect umbilical cord compression?
Which finding would lead the nurse to suspect umbilical cord compression?
Flashcards
Dystocia
Dystocia
Difficult labor arising from issues with the powers, passenger, or passage.
Induction of Labor
Induction of Labor
Initiating contractions artificially.
Augmentation of Labor
Augmentation of Labor
Enhancing ineffective contractions.
Hypotonic Contractions
Hypotonic Contractions
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Hypertonic Contractions
Hypertonic Contractions
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McRobert's Maneuver
McRobert's Maneuver
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Shoulder Dystocia
Shoulder Dystocia
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External Cephalic Version (ECV)
External Cephalic Version (ECV)
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Uterine Rupture
Uterine Rupture
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Umbilical Cord Prolapse
Umbilical Cord Prolapse
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Amniotic Fluid Embolism (AFE)
Amniotic Fluid Embolism (AFE)
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Version
Version
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External Cephalic Version (ECV)
External Cephalic Version (ECV)
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Internal Version
Internal Version
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Amnioinfusion
Amnioinfusion
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Oligohydramnios
Oligohydramnios
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Vacuum Extraction
Vacuum Extraction
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Forceps-Assisted Birth
Forceps-Assisted Birth
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Cesarean Birth
Cesarean Birth
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Study Notes
- Labor and birth complications pose risks to both the woman and the fetus/newborn, requiring prompt recognition and intervention.
- Dystocia, or difficult labor, can arise from various factors affecting the powers of labor, the passenger (fetus), or the passage (maternal pelvis).
- Induction of labor involves initiating contractions artificially, while augmentation enhances ineffective contractions.
Problems with the Powers
- Ineffective uterine contractions, either hypotonic (weak) or hypertonic (excessively strong), can impede labor progress.
- Hypotonic contractions: infrequent, brief, and of low intensity, often occurring in the active phase.
- Associated with factors like overdistention of the uterus, large fetus, medication, or maternal exhaustion.
- Nursing interventions: assess uterine activity, maternal/fetal status, promote position changes, ambulation, and provide hydration/nutrition.
- Oxytocin augmentation may be considered if no contraindications exist.
- Hypertonic contractions: frequent, prolonged, and of high intensity, usually occurring in the latent phase.
- Associated with anxiety or first-time mothers.
- Nursing interventions: pain relief measures, promote rest, hydration, and evaluate fetal response to contractions.
- Ineffective maternal pushing can result from incorrect techniques, fear of injury, or epidural anesthesia.
- Nursing interventions: provide education on effective pushing techniques, encourage open-glottis pushing, and optimize positioning.
Problems with the Passenger
- Fetal size, fetal presentation/position, multifetal pregnancy, and fetal anomalies can contribute to dystocia.
- Shoulder dystocia: occurs when the fetal shoulders become impacted after delivery of the head.
- Associated with macrosomia (large fetus) or maternal pelvic abnormalities.
- Nursing interventions: McRobert's maneuver (maternal legs flexed to abdomen) and suprapubic pressure to dislodge the shoulder.
- Abnormal fetal presentation or position (breech, transverse lie, face presentation) can hinder vaginal delivery.
- External cephalic version (ECV) may be attempted to convert a breech presentation to cephalic.
- Cesarean birth is often necessary for persistent malpresentations.
- Multifetal pregnancy increases the risk of complications such as preterm labor, malpresentation, and uterine atony.
- Nursing interventions: close monitoring of both fetuses, preparation for possible cesarean birth.
- Fetal anomalies, such as hydrocephalus or abdominal wall defects, may impede descent through the birth canal.
Problems with the Passage
- Pelvic structure abnormalities (small or abnormally shaped pelvis) can obstruct fetal passage.
- Maternal soft tissue obstructions, such as a full bladder or bowel, can also impede labor progress.
Induction and Augmentation of Labor
- Induction of labor: artificial initiation of labor.
- Indications: post-term pregnancy, premature rupture of membranes, maternal medical conditions.
- Contraindications: placenta previa, vasa previa, active herpes infection, umbilical cord prolapse.
- Methods: cervical ripening (prostaglandins or mechanical dilators), amniotomy, oxytocin infusion.
- Augmentation of labor: stimulation of ineffective contractions.
- Indications: hypotonic uterine dysfunction.
- Method: oxytocin infusion.
- Nursing interventions during induction/augmentation: monitor maternal vital signs, uterine contractions, fetal heart rate patterns, and assess for complications such as uterine tachysystole or fetal distress.
Maternal Soft Tissue Injuries
- Lacerations of the perineum, vagina, or cervix can occur during childbirth.
- Risk factors: precipitous labor, large fetus, operative vaginal delivery.
- Nursing interventions: assess and repair lacerations, provide pain relief, and monitor for signs of infection.
- Hematomas (collection of blood in tissues) can develop in the vulva, vagina, or retroperitoneal area.
- Nursing interventions: assess size and location of hematoma, apply ice packs, provide pain relief, and monitor for signs of shock.
Uterine Rupture
- Uterine rupture: a tear in the wall of the uterus, a life-threatening emergency.
- Risk factors: prior cesarean birth, uterine surgery, grand multiparity, and oxytocin induction.
- Signs and symptoms: sudden abdominal pain, vaginal bleeding, cessation of contractions, fetal distress.
- Nursing interventions: prepare for emergency cesarean birth, administer blood transfusions, and provide emotional support.
Umbilical Cord Prolapse
- Umbilical cord prolapse: occurs when the umbilical cord precedes the fetus in the birth canal.
- Risk factors: malpresentation, premature rupture of membranes, polyhydramnios.
- Nursing interventions: relieve pressure on the cord by elevating the fetal presenting part, administer oxygen, and prepare for immediate cesarean birth.
Amniotic Fluid Embolism
- Amniotic fluid embolism (AFE): occurs when amniotic fluid enters the maternal circulation, causing a severe allergic-like reaction.
- Signs and symptoms: sudden respiratory distress, cyanosis, hypotension, and disseminated intravascular coagulation (DIC).
- Nursing interventions: provide respiratory support, administer medications to manage hypotension and coagulopathy, and provide emotional support.
Version
- Version is a procedure used to turn the fetus from one presentation to another before birth. The two types of version are:
- External Cephalic Version (ECV) - Turning the fetus from a breech or shoulder presentation to a vertex presentation by abdominal manipulation.
- Internal Version - The obstetrician inserts a hand into the uterus and manually manipulates the fetus into a longitudinal lie (cephalic or breech) to allow for vaginal delivery. Internal version is used almost exclusively during vaginal birth of twins to deliver the second twin.
Amnioinfusion
- Amnioinfusion is the infusion of sterile isotonic solution into the uterus to increase the volume of amniotic fluid.
- Reasons for amnioinfusion include:
- Oligohydramnios (lower than normal amount of amniotic fluid)
- Umbilical cord compression
- Dilution of meconium-stained amniotic fluid
Vacuum Extraction
- Vacuum extraction involves using a cup attached to a suction pump to assist in the delivery of the fetal head.
- Indications: prolonged second stage of labor, fetal distress.
- Risks: scalp lacerations, cephalohematoma, and subgaleal hematoma in the newborn.
Forceps-Assisted Birth
- Forceps-assisted birth involves using forceps to grasp the fetal head and assist in delivery.
- Indications: prolonged second stage of labor, fetal distress.
- Risks: maternal lacerations, hematomas, and fetal bruising.
Cesarean Birth
- Cesarean birth is the surgical delivery of the fetus through an incision in the abdomen and uterus
- Indications: malpresentation, fetal distress, placental abnormalities, active herpes infection.
- Nursing interventions: preoperative teaching, postoperative pain management, and assessment for complications such as infection or hemorrhage.
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