high risk intrapartum.docx

1. A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4...

1. A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia. 2. The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes. 3. A client, 38 weeks’ gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician. 4. An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman’s primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse’s action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature. 5. A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress. 3809_Ch09_279-318 14/02/13 4:49 PM Page 280 CHAPTER 9 HIGH-RISK INTRAPARTUM 281 6. A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen. 3. Change her position. 4. Monitor her labor. 7. A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes? 1. Intravenously. 2. Orally. 3. Endocervically. 4. Intrathecally. 8. A woman, 402⁄ 7 weeks’ gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units oxytocin (Pitocin) to be diluted in 1,000 mL D51⁄ 2 NS. The order reads: Administer oxytocin IV at 0.5 milliunits per min. Calculate the drip rate for the infusion pump to be programmed. Please calculate to the nearest whole number. __________ mL/hr. 9. The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse’s action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed. 10. A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F. 11. A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor. 12. The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1 P0000 contracting every 20 minutes × 30 seconds. 4. G6 P3202 with blood pressure 140/90 and pulse 92. 13. A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute. 3809_Ch09_279-318 14/02/13 4:49 PM Page 281 14. There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3 P0020, in active labor. 2. Age 22, G1 P0000, eclampsia. 3. Age 25, G4 P3003, last delivery by cesarean section. 4. Age 32, G2 P0100, first baby died during labor. 15. A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate. 16. A client, 39 weeks’ gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days “because I keep leaking urine.” Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman’s bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman’s uterus and monitor for ballottement. 17. The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler’s position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate. 18. Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply. 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid. 5. Woman with fetus in the occiput posterior position. 19. A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation. 20. A woman, 39 weeks’ gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed. 21. A client telephones the labor and delivery suite and states, “My bag of waters just broke and it smells funny.” Which of the following responses would be appropriate for the nurse make at this time? 1. “Have you notified your doctor of the smell?” 2. “The bag of waters always has an unusual odor.” 3. “Your labor should start very soon.” 4. “Have you felt the baby move since the membranes broke?” 282 MATERNAL AND NEWBORN SUCCESS 3809_Ch09_279-318 14/02/13 4:49 PM Page 282 22. A client, G3 P2002, 40 weeks’ gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman? 1. She may need a cesarean delivery. 2. She will be treated with antibiotics during labor. 3. The baby may develop thrush after delivery. 4. The baby will be isolated for at least one day. 23. A woman who is hepatitis B–surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery. 24. A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take? 1. Check dilation and effacement. 2. Prepare the client for surgery. 3. Place the bed in Trendelenburg position. 4. Check the biophysical profile results. 25. Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 120 with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta. 26. Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman’s vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings. 27. A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station –3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie. 28. A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post–spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes. CHAPTER 9 HIGH-RISK INTRAPARTUM 283 3809_Ch09_279-318 14/02/13 4:49 PM Page 283 29. A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta. 30. A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing. 31. The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations. 32. A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman’s doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support. 33. Given the fetal heart rate pattern shown below, which of the following interventions should the nurse perform first? 284 MATERNAL AND NEWBORN SUCCESS 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 1. Increase the intravenous drip rate. 2. Apply oxygen by face mask. 3. Turn the woman on her side. 4. Report the tracing to the obstetrician. 3809_Ch09_279-318 14/02/13 4:49 PM Page 284 34. Which of the tracings shown below would the nurse interpret as indicative of uteroplacental insufficiency? CHAPTER 9 HIGH-RISK INTRAPARTUM 285 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 240 210 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 1. 2. 3. 4. 3809_Ch09_279-318 14/02/13 4:49 PM Page 285 35. A client’s assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration. 36. When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow. 37. A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions. 38. The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal, warranting further sampling. 4. The results are within normal limits. 39. A client is in active labor. Which of the following assessments would warrant immediate intervention? 1. Maternal PaCO2 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. Fetal scalp sampling pH of 7.19. 40. A woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dypsneic and cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion. 41. Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor? 1. Client will be infection free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge. ANSWERS AND RATIONALES The correct answer number and rationale for why it is the correct answer are given in boldface blue type. Rationales for why the other possible answer options are incorrect also are given, but they are not in boldface type. 1. 1. These are the classic signs of water intoxication. 2. With water intoxication, the woman would show signs of hyponatremia and hypokalemia. 3. Thrombocytopenia and neutropenia are unrelated to water intoxication. 4. Paresthesias, myalgias, and anemia are unrelated to water intoxication. TEST-TAKING TIP: Clients who receive oxytocin over a long period of time are at high risk for water intoxication. The oxytocin molecule is similar in structure to the antidiuretic hormone (ADH) molecule. The body retains fluids in response to the medication much the same way it would in response to ADH. The nurse, therefore, should carefully monitor intake and output when clients are induced with oxytocin. 2. 1. Induction is contraindicated in transverse lie. 2. When indicated, it is safe to induce a woman with cerebral palsy. 3. When indicated, it is safe to induce a pregnant adolescent. 4. When indicated, it is safe to induce a woman with diabetes mellitus. TEST-TAKING TIP: A baby in the transverse lie is in a scapular presentation. The baby is incapable of being birthed vaginally. Whenever a vaginal birth is contraindicated, induction is also contraindicated. 3. 1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. 2. Oxygen should be administered, but the mask should be put on after the oxytocin has been turned off. 3. Repositioning is indicated, but should be performed after the oxytocin has been turned off. 4. The obstetrician should be called, but after the oxytocin has been turned off. TEST-TAKING TIP: Oxytocin stimulates the contractility of the uterine muscle. When the muscle is contracted, the blood flow to the placenta is reduced. Whenever there is evidence of fetal compromise and oxytocin is being infused, the intravenous should be stopped immediately to maximize placental perfusion. 4. 1. As long as oxytocin is increased slowly and the contraction pattern and fetal response are monitored carefully, there is no absolute, unsafe maximum dosage of oxytocin. 2. The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes. 3. Although postdates babies are higher risk for fetal distress, it is not contraindicated to induce with oxytocin. 4. A 60-second contraction duration is normal. TEST-TAKING TIP: The half-life (the time it takes half of a medication to be metabolized by the body) of oxytocin is relatively long— about 15 minutes. And at least 3 half-lives usually elapse before therapeutic responses are noted. Increasing the infusion rate too rapidly, therefore, can lead to hyperstimulation of the uterine muscle and consequent fetal distress. 5. 1. A common side effect of Cytotec is diarrhea and labor contractions are often first felt in the back. 2. Hypothermia and rectal pain are not associated with Cytotec administration. 3. Urinary retention and rash are not associated with Cytotec administration. 4. Tinnitus and respiratory distress are not associated with Cytotec administration. TEST-TAKING TIP: Cytotec (misoprostol) is a synthetic prostaglandin medication used to ripen the cervix for induction. Gastrointestinal side effects are commonly seen when prostaglandin is used, because the gastrointestinal system is adjacent to the vagina where the medication is inserted. In addition, the nurse must be watchful for signs of labor. 6. 1. The infusion should be maintained. 2. There is no indication for oxygen at this time. 3. If she is comfortable, there is no need to change her position. 4. It is appropriate to monitor the woman’s labor. TEST-TAKING TIP: Even if the test taker were unfamiliar with a normal contraction 3809_Ch09_279-318 14/02/13 4:49 PM Page 297 298 MATERNAL AND NEWBORN SUCCESS pattern—as seen in the stem of the question—if he or she knew that the fetal heart pattern is normal, he or she could deduce the correct answer. Three of the responses infer that the nurse should take action because of a complication. Only response 4 indicates that the nurse should continue monitoring the labor. In this situation, the one response that is different from the others is the correct answer. 7. 1. Prepidil is not administered intravenously 2. Prepidil is not administered orally. 3. Prepidil is administered endocervically. 4. Prepidil is not administered intrathecally. TEST-TAKING TIP: Prostaglandins, hormonelike substances that mediate a wide range of physiological functions, do so locally. Prepidil, therefore, is administered adjacent to the cervix where it acts to soften the cervix in preparation for dilation and effacement. 8. 3 mL/hr. TEST-TAKING TIP: The nurse must do a number of calculations to determine the pump drip rate in this client. First, the nurse must determine how many milliunits are in 1,000 mL of fluid: 10 units in 1,000 mL = 10,000 milliunits in 1,000 mL Next, the nurse must determine how many milliunits are to be infused per hour (because pumps are always calibrated mL/hour): 0.5 millliunits per minute = 30 milliunits per 60 minutes Finally, the nurse must do a ratio and proportion to determine the mL per hour: 10,000 milliunits/1000 mL = 30 milliunits/x mL x = 3 mL/hr 9. 1. Uterine hyperstimulation can be seen with moderate intensities. 2. A frequency pattern of every 3 minutes is ideal. 3. A duration of 130 seconds is indicative of tachysystole. 4. The attitude of the baby has nothing to do with hyperstimulation. TEST-TAKING TIP: This question is asking the test taker to evaluate an expected outcome. When a nurse intervenes, he or she is expecting a positive outcome. In this situation, the nurse is determining whether or not the action has reversed the hyperstimulation that developed from oxytocin administration. The normal contraction frequency is evidence of a positive outcome. 10. 1. The pulse rate has likely increased because the woman is working with her labor. It is not an indication to turn off the oxytocin. 2. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped. 3. Hypertension is not an indication to stop oxytocin administration. 4. Hyperthermia is not an indication to stop oxytocin administration. TEST-TAKING TIP: The test taker must determine which of the vital signs is unsafe in the presence of oxytocin. Oxytocin increases the contractility of the uterine muscle. When the muscle contracts, the blood supply to the fetus is diminished. A drop in fetal heart rate, therefore, is indicative of poor oxygenation to the fetus and is unsafe in the presence of oxytocin. 11. 1. There is no indication in the scenario that the membranes have ruptured. 2. The Bishop score is expected to rise when Cervidil is administered. 3. There is no sign of distress in the scenario; therefore, a change in position is unnecessary. 4. The nurse should monitor this client for the onset of labor. TEST-TAKING TIP: The Bishop score indicates the inducibility of the cervix of a client. Five signs are assessed—cervical position, cervical dilation, cervical effacement, cervical station, and cervical consistency. A total score is calculated. A primigravid cervix is considered inducible when the Bishop score is 9 or higher. A multigravid cervix is considered inducible when the Bishop score is 5 or higher. 3809_Ch09_279-318 14/02/13 4:49 PM Page 298 12. 1. A primipara with a Bishop score of 4 is not inducible with oxytocin. Prepidil helps to improve cervical readiness for an oxytocin induction. 2. This client’s fetus is already showing signs of fetal distress. Induction increases the risk of fetal injury. 3. This woman’s contractions are not effective. The medicine may help to promote more effective labor. 4. Neither a high gravidity nor an elevated blood pressure is a contraindication to Prepidil administration. TEST-TAKING TIP: It is important to remember that although the fetus of a pregnant woman may be at term, it is not always safe for labor contractions to be stimulated. Although Prepidil is not directly used for induction, it is an agent that promotes cervical ripening in preparation for labor. A baby who is exhibiting signs of poor uteroplacental blood flow is likely to be compromised further by the addition of the medication. 13. 1. The expected outcome from the administration of Cervidil is an increase in the Bishop score. 2. A fetal heart rate of 152 is within normal limits and not significantly different from the original baseline of 156. 3. A respiratory rate of 24 is not a contraindication to the administration of prostaglandins for cervical ripening. 4. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication. TEST-TAKING TIP: A frequency of 1 minute, even if the duration were 30 seconds, would mean that there were only 30 seconds when the uterine muscle was relaxed. This short amount of time would not provide the placenta with enough time to be sufficiently perfused. Fetal bradycardia is a likely outcome to such a short frequency period. 14. 1. Although this teenager has had two abortions, she is not markedly at high risk for uterine rupture. 2. A primigravida with eclampsia is not markedly at high risk for uterine rupture. 3. A woman, no matter what her age, who has had a previous cesarean section is at risk for uterine rupture. 4. A woman who has a history of fetal death is not markedly at high risk for uterine rupture. TEST-TAKING TIP: When babies are birthed via cesarean section, the surgeon must create an incision through the uterine body. The muscles of the uterus have, therefore, been ligated and a scar has formed at the incision site. Scars are not elastic and do not contract and relax the way muscle tissue does. A vaginal birth after cesarean (VBAC) section can be performed only if the woman had a low flap (Pfannenstiel) incision in the uterus during her previous cesarean section. 15. 1. Frequency and duration are important, but they are not the highest priority at this time. 2. Maternal temperature is the highest priority. 3. Cervical change is important, but it is not the highest priority at this time. 4. Maternal pulse rate is important, but it is not the highest priority at this time. TEST-TAKING TIP: The test taker must remember that the uterine cavity is a CHAPTER 9 HIGH-RISK INTRAPARTUM 299 Prelabor Status Evaluation Scoring System Score 0 1 23 Cervical position Posterior Midposition Anterior — Cervical consistency Firm Medium Soft — Cervical effacement (%) 0–30 40–50 60–70 ≥0 Cervical dilation (cm) Closed 1–2 3–4 ≥5 Fetal station –3 –2 –1 +1/+2 Adapted from Bishop, E.H. (1964). Pelvic scoring for elective induction. Obstetrics & Gynecology, 24, 266. 3809_Ch09_279-318 14/02/13 4:49 PM Page 299 300 MATERNAL AND NEWBORN SUCCESS sterile space and the vaginal vault is an unsterile space. When membranes have ruptured over 24 hours, there is potential for pathogens to ascend into the uterine cavity and infection to result. Elevated temperature is a sign of infection. 16. 1. It is unlikely that the woman has a distended bladder. 2. Although the woman may have a UTI, an order is needed for a urine culture. This is not the first action that the nurse should take. 3. The fluid should be assessed with nitrazine paper. 4. This action is not a priority at this time. TEST-TAKING TIP: Nitrazine paper is another name for litmus paper. It detects the pH of fluid. Amniotic fluid is alkaline, whereas urine is acidic. If the paper turns a dark blue, the nurse can conclude that the membranes have ruptured and that the woman is leaking amniotic fluid. 17. 1. Oxygen administered during labor should be delivered via a tight-fitting mask at 8 to 10 liters per minute. 2. The client should be positioned on her side or in Trendelenburg position. 3. The best way to monitor the fetus is with an internal electrode. 4. Increasing the IV rate helps to improve perfusion to the placenta. TEST-TAKING TIP: Because the fetus is being oxygenated via the placenta, it is essential that in cases of fetal distress, the amount of oxygen perfusing the placenta be maximized. That requires high concentrations of oxygen being administered via mask, blood volume being increased by increasing the IV drip rate, and cardiac blood return being maximized by positioning the client to remove pressure from the aorta and the vena cava. 18. 3 and 4 are correct. 1. The transition phase is an excellent time to use hydrotherapy. 2. Many women do push during second stage in the water bath. 3. Women undergoing induction should not labor in a water bath. During induction, the fetus should be monitored continually by electronic fetal monitoring. 4. Meconium-stained amniotic fluid may indicate fetal distress. Continuous electronic fetal monitoring would, therefore, be indicated. 5. A posterior fetal position is not a contraindication for the use of a water bath. TEST-TAKING TIP: Hydrotherapy is an excellent complementary therapy for the laboring woman. The warm water is relaxing and many women find that their pain is minimized. Induction and continuous electronic fetal monitoring, however, are incompatible with the intervention. 19. 1. Intermittent fetal heart auscultation is appropriate at this time. 2. Vaginal examination is contraindicated. 3. Intravenous fluid administration is appropriate at this time. 4. Nipple stimulation is appropriate at this time. TEST-TAKING TIP: The client in this scenario is at risk of an ascending infection from the vagina to the uterine body because she has prolonged rupture of membranes. Any time a vaginal examination is performed, the chance of infection rises. Nipple stimulation is appropriate because endogenous oxytocin will be released, which would augment the client’s weak labor pattern. 20. 1. Human papillomavirus is not an indication for cesarean section. 2. Standard precautions are indicated in this situation. 3. A baby born to a woman with HPV receives standard care in the well-baby nursery. 4. HPV is not airborne. A mask is not required. TEST-TAKING TIP: Although HPV is a sexually transmitted infection and it can in rare instances be contracted by the neonate from the mother, the Centers for Disease Control and Prevention do not recommend that cesarean section be performed merely to prevent vertical transmission of HPV (see http://www.cdc.gov/std/HPV/STDFact-HPV.htm). 21. 1. This comment is inappropriate. The nurse should ask the woman whether or not she has felt fetal movement. 2. The amniotic fluid smells musty but it does not naturally have an offensive smell. 3. This statement is likely true but the nurse should ask the woman whether or not she has felt fetal movement and the woman should be advised to go to the hospital for evaluation. 4. The most important information needed by the nurse should relate to 3809_Ch09_279-318 14/02/13 4:49 PM Page 300 the health and well-being of the fetus. Fetal movement indicates that the baby is alive. TEST-TAKING TIP: There are two concerns in this scenario: the fact that the membranes just ruptured and the smell of the fluid. The nurse should, therefore, consider two possible problems: possible prolapsed cord, which may occur as a result of the rupture of the amniotic sac, and possible infection, which may be indicated by the smell. Normal fetal movement will give the nurse some confidence that the cord is not prolapsed. This is the first question that should be asked. Then, the client should be encouraged to go to the hospital to be assessed for possible infection and signs of labor. 22. 1. Candidiasis is not an indication for cesarean section. 2. Candida is a fungus. Antibiotics do not treat this problem. 3. Thrush is the term given to oral candidiasis, which the baby may develop after delivery. 4. There is no need to isolate a baby born to a woman with candidiasis. TEST-TAKING TIP: Candida can be transmitted to a baby during delivery as well as postdelivery via the mother’s hands. Initially, the baby will develop thrush, but eventually the mother may notice a bright pink diaper rash on the baby. Also, if she is breastfeeding her baby, she may develop a yeast infection of the breast that is very painful. The mother with candidiasis should be advised to wash her hands carefully after toileting. 23. 1. Cesarean delivery is not recommended for women who are hepatitis B positive. 2. Ampicillin is ineffective against hepatitis B, which is a virus. Ampicillin may be administered to women who have group B strep vaginal or rectal cultures. 3. Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG. 4. Babies born to women who are hepatitis B–surface antigen positive are cared for in the well-baby nursery. No isolation is needed. TEST-TAKING TIP: Although this is a woman who is in labor, the nurse must anticipate the needs of the neonate after delivery. Because it is recommended that the baby receive the medication within a restricted time frame, it is especially important for the nurse to be proactive and obtain the physician’s order (see http://www.cdc.gov/ hepatitis/HBV/PDFs/DeliveryHospital PreventPerinatalHBVTransmission.pdf). 24. 1. It is appropriate for the nurse to assess the client’s dilation and effacement. 2. Surgical delivery is not indicated by the scenario. 3. There is no reason to place the client in the Trendelenburg position. 4. There is no indication that a BPP has been performed. TEST-TAKING TIP: Although cesarean deliveries are recommended to be performed when a client has an active case of herpes simplex, surgical delivery is not indicated when no lesions are present. Clients who have histories of herpes with no current outbreak, therefore, are considered to be healthy laboring clients who may deliver vaginally (see http://www.cdc.gov/std/treatment/2006/specialpops.htm#specialpops1). 25. 1. There are no signs of placenta abruption in this scenario. 2. The woman has not seized. She is not eclamptic. 3. The drop in fetal heart rate with variable decelerations indicates that the cord has likely prolapsed. 4. There are no signs that this client has a succenturiate placenta. TEST-TAKING TIP: The test taker must remember that variable decelerations are caused by cord compression. The fact that variables are seen in the scenario as well as a precipitous drop in the fetal heart baseline is an indirect indication that the cord is being compressed, resulting in decreased oxygenation to the fetus. 26. 1. The first action the nurse should take is to place the woman in the knee-chest position. 2. The nurse should assess the fetal heart rate, but this is not the first action. 3. Oxygen should be administered, but this is not the first action. 4. The physician should be advised, but this is not the first action. TEST-TAKING TIP: The weight of the fetus on the prolapsed cord can rapidly result in fetal death. Therefore, the nurse must act quickly to relieve the pressure on the CHAPTER 9 HIGH-RISK INTRAPARTUM 301 3809_Ch09_279-318 14/02/13 4:49 PM Page 301 302 MATERNAL AND NEWBORN SUCCESS cord. Additional actions that can take pressure off the cord are placing the client in the Trendelenburg position and pushing the head off the cord with a gloved hand. This situation is an obstetric emergency. 27. 1, 2, and 5 are correct. 1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. 2. The presenting part is floating, which increases the risk of prolapsed cord. 3. With decreased quantity of amniotic fluid there is no increased risk of prolapsed cord. 4. 2-cm dilation is not a situation that is at high risk for prolapsed cord. 5. When a baby is in the transverse lie, there is increased risk for prolapsed cord. TEST-TAKING TIP: Once the membranes have ruptured, there are several situations that can increase the possibility of the cord prolapsing, i.e., when the cord slips past the baby and becomes the presenting part. The baby then compresses the cord, preventing the baby from being oxygenated. The situations include malpresentations, like breech and shoulder presentations. A shoulder presentation is the same as a transverse lie. Additional situations that are at high risk for cord prolapse are hydramnios, premature rupture of membranes, and negative fetal station. 28. 1. Although the blood glucose of a client with diabetes is important, it can wait. 2. Although the vaginal blood loss assessment of a client who has had a spontaneous abortion is important, it is usually minimal. This client can wait. 3. It is important to assess the patellar reflexes of a client with preeclampsia, but with mild disease, that action can wait. 4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency. TEST-TAKING TIP: Identifying the priority action is the most difficult thing that nurses must do. The nurse must determine which of the situations is most life threatening. Of the four choices above, prolapsed cord is life threatening to the fetus. None of the other situations, as stated in the question, is life threatening to either the mother or the fetus. 29. 1. Prolonged labor is not associated with maternal illicit drug use. 2. Prolapsed cord is not associated with maternal illicit drug use. 3. Placental abruption is associated with maternal illicit drug use. 4. Retained placenta is not associated with maternal illicit drug use. TEST-TAKING TIP: Crack cocaine is a powerful vasoconstrictive agent. The chorionic villi atrophy as a result of the vasoconstrictive effects of the drug. Placental abruption, when the placenta detaches from the decidual lining of the uterus, is therefore of particular concern. 30. 1. It is inappropriate to discourage a laboring client from taking pain medication simply because she has abused drugs. 2. The nurse should notify the health care practitioner of the client’s request. 3. Substance abuse is not a contraindication for analgesic medication in labor. 4. Although the client may benefit from labor breathing, she has requested pain medication and that request should be acted upon. TEST-TAKING TIP: The test taker should be aware of two important facts: Pain is the fifth vital sign as identified by The Joint Commission, and actions must be taken to reduce drug abusers’ pain in the same manner that non–drug abusers’ pain is managed. Although it is strongly discouraged for women to take illicit drugs when pregnant, the nurse must maintain his or her caring philosophy and provide unbiased care to addicted clients. 31. 1. This baby is high risk for the development of late fetal heart decelerations. 2. Based on the scenario, neither mother nor baby is at high risk for hyperthermia. 3. Based on the scenario, neither mother nor baby is at high risk for hypertension. 4. Early decelerations are normal. They are usually seen during transition and stage 2. TEST-TAKING TIP: The test taker must attend to all important information in the question. The gestational age of this fetus is 43 weeks. The baby and placenta, therefore, are both postdates. Placental function usually deteriorates after 40 weeks’ gestation. As late decelerations result from poor uteroplacental blood flow, the nurse should monitor this client carefully for late decelerations. 3809_Ch09_279-318 14/02/13 4:49 PM Page 302 32. 1. The woman does have a legal right not to sign the form. To badger her about her decision is inappropriate. 2. Practitioners who perform surgery on a client who has refused to sign a consent form can be arrested for assault and battery. 3. It is inappropriate to scare a patient into submission. 4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated. TEST-TAKING TIP: If the client’s practitioner is convinced that surgery is the only appropriate intervention, he or she could get a court order to mandate the woman to accept surgery. The nurse’s role at this point, however, is to provide the client with care in a nonthreatening, compassionate manner. The nurse must acknowledge and accept the client’s legal right to refuse the surgery. 33. 1. Increasing the IV rate is appropriate, but it is not the first action that should be taken. 2. Applying oxygen via face mask is appropriate, but it is not the first action that should be taken. 3. Repositioning the woman is the first action that should be taken. 4. Although the decelerations should be reported to the health care practitioner, this is not the first action that should be taken. TEST-TAKING TIP: To answer this question, the test taker must fully understand the etiology of the decelerations. Variable decelerations occur as a result of umbilical cord compression. It is possible, therefore, that if the mother is positioned differently, the pressure will be shifted and the decelerations will resolve. If the first position change does not resolve the problem, the nurse should try additional position changes. It is also important for the nurse to do all that he or she can to resolve the problem—by administering oxygen and increasing the IV drip rate—before calling the physician. To do otherwise could constitute patient abandonment. 34. 1. This monitor tracing shows a variable fetal heart baseline. This is a tracing of a well-oxygenated fetus. 2. This monitor tracing shows a variable fetal heart baseline with early decelerations. Early decelerations are related to head compression. This is a normal finding during transition and stage 2 of labor. 3. This monitor tracing shows a fetal heart baseline with minimal variability and with late decelerations. These decelerations are related to uteroplacental insufficiency. 4. This monitor tracing shows a variable fetal heart baseline with accelerations. This depicts a well-oxygenated fetus. TEST-TAKING TIP: A tracing that depicts decelerations that begin late in a contraction and return to baseline well past the time that the contraction ends are called late decelerations. Late decelerations are related to poor uteroplacental blood flow. 35. 1. This client is only 4 cm dilated. Unless the late decelerations resolve, completion of stage 1 is not a priority. 2. The nurse’s goal at this point must be the delivery of a healthy baby. 3. Because late decelerations are present, pain management is not a priority at this time. 4. Unless the late decelerations resolve, this client may not deliver vaginally. TEST-TAKING TIP: Nursing goals may change repeatedly during a client’s labor. The nurse must assess the woman’s progress in relation to the health and well-being of the fetus. As long as the baby is responding well, the nurse’s focus should relate to maternal comfort and care. Once fetal compromise is noted, however, nursing actions often shift. 36. 1. Diminished variability is an indication of fetal acidosis. 2. Decelerations related to head compression mirror contractions and occur at the same time as the contractions (early decelerations). 3. The contractions described in the scenario result from cord compression (variable decelerations). 4. Decelerations related to uteroplacental insufficiency mirror contractions but begin late in the contraction and return to baseline after the contraction ends (late decelerations). TEST-TAKING TIP: First, the test taker should be able to interpret fetal heart tracings both visually and verbally. This includes baseline data as well as acceleration and deceleration changes. Second, the test taker should know the CHAPTER 9 HIGH-RISK INTRAPARTUM 303 3809_Ch09_279-318 14/02/13 4:49 PM Page 303 304 MATERNAL AND NEWBORN SUCCESS etiology of each of the tracings. Third, the test taker should know the appropriate nursing intervention related to each tracing. 37. 1. Although breathing with contractions is important, the nurse must notify the practitioner as soon as possible. 2. Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of Demerol (meperidine) or Stadol (butorphanol) administration. As this client has just been admitted, medication administration is not a likely cause. The health care practitioner should be notified. 3. Increasing the intravenous fluid rate will not help to resolve any of these severe fetal problems. 4. There is no indication in the scenario that this client is fully dilated. TEST-TAKING TIP: Sinusoidal fetal heart patterns exhibit no variability and have a uniform wave-like pattern (see below). The nurse would note no periods when the heart rate appears normal. The fetus is in imminent danger. The practitioner must be notified as soon as possible so that he or she can determine the appropriate intervention. fetal pH is defined as 7.25 to 7.35. An acidotic fetus has a pH that is less than 7.20. When the pH is between 7.20 to 7.25, the value is considered to be equivocal with a need for further testing. Usually interventions are instituted—oxygen applied, position changed, IV fluid increased—and another sampling is done in 10 to 15 minutes. 39. 1. The normal PaCO2 of an adult is 35 to 45 mm Hg. There is no need to intervene, therefore, if the PaCO2 is 40 mm Hg. 2. Although the alpha-fetoprotein level is well above normal, high levels of AFP are indicative of spina bifida, not of an acute problem. 3. Fetal heart accelerations, especially when they occur during contractions, are indicative of fetal well-being. 4. A fetal scalp pH of 7.19 is indicative of an acidotic fetus. TEST-TAKING TIP: The test taker must read all four responses before choosing the best one. Although answer 2 includes a value that is not normal, it does not describe a situation that requires the nurse to take immediate action. A fetal scalp sampling pH below 7.20, however, is of immediate concern. 40. 1. Blood pressure assessment is important, but it is not the priority action. 180 150 120 90 60 30 180 150 120 90 60 30 180 150 120 90 60 30 100 80 60 40 20 0 100 80 60 40 20 0 100 80 60 40 20 0 180 150 120 90 60 30 100 80 60 40 20 0 38. 1. The results are equivocal; therefore, the nurse cannot conclude that the baby is severely acidotic. 2. Practitioners usually will repeat the test a few minutes after an equivocal result. 3. Further testing is indicated. 4. The results are not within normal limits. TEST-TAKING TIP: Some practitioners perform fetal scalp sampling when there is a decrease in fetal heart variability. A normal 2. FH assessment is important, but it is not the priority action. 3. The nurse’s priority action is to administer oxygen. 4. It is appropriate to stop the infusion, but that is not the priority action. TEST-TAKING TIP: This client is exhibiting the classic signs of an amniotic fluid embolism. At this point, the baby’s health is secondary because the mother is in a 3809_Ch09_279-318 14/02/13 4:49 PM Page 304 life-threatening situation. The nurse must apply oxygen and call a code immediately. 41. 1. Infection is not directly related to the presence of amniotic fluid emboli. 2. The appropriate nursing care outcome is that the client survives and is breathing normally at discharge. 3. Gastrointestinal function is not related to the presence of amniotic fluid emboli. 4. Urinary function is not related to the presence of amniotic fluid emboli. TEST-TAKING TIP: At the time of placental separation or during stage 1 of labor, a small amount of amniotic fluid sometimes seeps into the mother’s bloodstream via the chorionic villi. With the contraction of the uterus, the fluid is shunted into the peripheral circulation and forced into the woman’s lung fields. If there is meconium or other foreign material in the fluid, the woman’s prognosis declines. Women who experience forceful, rapid labors are especially at risk for this life-threatening complication