Chapter 16: Nursing Care During Obstetric Procedures My Nursing Test Banks

Chapter 16: Nursing Care During Obstetric Procedures

MULTIPLE CHOICE

1. The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. The correct rationale for this intervention is that:

a.

a sterile urine specimen is needed preoperatively.

b.

an empty bladder provides more room in the pelvis.

c.

spontaneous release of urine might contaminate the sterile field.

d.

a Foley catheter prevents the membranes from spontaneously rupturing.

ANS: B

Catheterization provides room for the application of the forceps blades and limits bladder trauma. A clean-catch urinalysis is usually sufficient for preoperative treatment. Urine is sterile. The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 314

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

2. After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

a.

Lack of an episiotomy

b.

Mild, intermittent perineal pain

c.

Lack of pain in the perineal area

d.

Edema and discoloration of the labia and perineum

ANS: D

The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe.

PTS: 1 DIF: Cognitive Level: Understanding REF: 314

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. The nurse is positioning the Foley catheter prior to a cesarean birth. Which position should the nurse use to place the catheter drainage tubing and catheter bag?

a.

Place near the head of the table.

b.

Position on top of the patients leg.

c.

Place at the foot and clamp during the cesarean section.

d.

Position at the foot of the surgeon under the sterile drapes.

ANS: A

The drain tube of the catheter should be positioned under the clients to promote drainage and to keep the catheter away from the operative area. Urinary output must be continuously monitored. An early sign of hypovolemia is decreasing urinary output. The anesthesia clinician must monitor urine output during the surgery so it should not be clamped. The surgeon might step on the drainage bag if the catheter were below the drapes, and no one could monitor the urine output.

PTS: 1 DIF: Cognitive Level: Application REF: 322

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

4. Which condition is a contraindication for an amniotomy?

a.

2 station

b.

Breech presentation

c.

Dilation less than 3 cm

d.

Right occiput posterior position

ANS: A

A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged. The presenting part should be cephalic. The dilation must be enough to determine labor. Right occiput posterior is a cephalic presentation appropriate for an amniotomy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 305

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. Which client status is an acceptable indication for serial oxytocin induction of labor?

a.

Multiple fetuses

b.

Polyhydramnios

c.

History of long labors

d.

Past 42 weeks of gestation

ANS: D

Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus, making induction of labor high risk. Polyhydramnios overdistends the uterus, making induction of labor high risk. A history of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances.

PTS: 1 DIF: Cognitive Level: Understanding REF: 308

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

6. The nurse is explaining the technique of internal version to a group of nursing students. Which describes the technique of internal version?

a.

Manipulation of the fetus from a breech to a cephalic presentation before labor begins

b.

Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth

c.

Manipulation of the second twin from an oblique lie to a transverse lie before labor begins

d.

Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

ANS: D

Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal version is done to turn the second twin after the first twin is born.

PTS: 1 DIF: Cognitive Level: Application REF: 311

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. The greatest risk to the newborn after an elective cesarean birth is:

a.

tachypnea because of maternal anesthesia.

b.

tachycardia because of maternal narcotics.

c.

trauma because of manipulation during birth.

d.

prematurity because of miscalculation of gestation.

ANS: D

Regardless of the many criteria used to determine gestational age, inadvertent preterm birth still occurs. Maternal anesthesia may cause respiratory distress. Maternal narcotics may cause respiratory distress. There is less trauma with a cesarean birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 317

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. Which client is most at risk for a uterine rupture?

a.

A gravida 4 who had a classic cesarean incision

b.

A gravida 5 who had two vaginal births and one cesarean birth

c.

A gravida 3 who has had two low-segment transverse cesarean births

d.

A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

ANS: A

The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The client who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low-segment incisions do not raise the risk of uterine ruptures.

PTS: 1 DIF: Cognitive Level: Understanding REF: 317

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

9. Before the health care provider performs an external version, the nurse should expect an order for a:

a.

Foley catheter.

b.

tocolytic drug.

c.

local anesthetic.

d.

contraction stress test (CST).

ANS: B

A tocolytic drug will relax the uterus before and during version, making manipulation easier. The bladder should be emptied, but catheterization is not necessary. A local anesthetic is not used with external version. CST is used to determine the fetal response to stress.

PTS: 1 DIF: Cognitive Level: Analysis REF: 312

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

10. A maternal indication for the use of vacuum extraction is:

a.

a wide pelvic outlet.

b.

maternal exhaustion.

c.

a history of rapid deliveries.

d.

failure to progress past 0 station.

ANS: B

The client who is exhausted will be unable to assist with the expulsion of the fetus. With a wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum extraction would not be necessary. A station of 0 is too high for a vacuum extraction.

PTS: 1 DIF: Cognitive Level: Understanding REF: 313

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. The priority nursing intervention following an amniotomy is to:

a.

change the clients gown.

b.

assess the fetal heart rate.

c.

assess the color of the amniotic fluid.

d.

estimate the amount of amniotic fluid.

ANS: B

The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Changing the gown is important for client comfort but is not the top priority. Assessing the amount of amniotic fluid is important but is not the top priority. Estimating the amount of amniotic fluid is not a top priority for this client.

PTS: 1 DIF: Cognitive Level: Application REF: 305

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

12. For which client should the oxytocin (Pitocin) infusion be discontinued immediately?

a.

A client in transition with contractions every 2 minutes lasting 90 seconds each

b.

A client in early labor with contractions every 5 minutes lasting 40 seconds each

c.

A client in active labor with contractions every 3 minutes lasting 60 seconds each

d.

A client in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each

ANS: A

This clients contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this clients contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this clients contractions. There is an appropriate resting period between this clients contractions for her stage of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 306

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

13. The priority nursing care associated with an oxytocin infusion is:

a.

measuring urinary output.

b.

evaluating cervical dilation.

c.

monitoring uterine response.

d.

increasing infusion rate every 30 minutes.

ANS: C

Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurses priority intervention is monitoring uterine response. Monitoring urinary output is important with Pitocin but not the top priority. Monitoring labor progression is important but not the top priority. The infusion rate may be increased but only after proper assessment that it is appropriate.

PTS: 1 DIF: Cognitive Level: Application REF: 306

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

14. Which event indicates a complication of an external version?

a.

Maternal pulse rate of 100 bpm

b.

Fetus returning to the original position

c.

Increased maternal anxiety after the version

d.

Fetal bradycardia persisting 10 minutes after the version

ANS: D

Fetal bradycardia after a version may indicate that the umbilical cord has become compressed, and the fetus is having hypoxia. There are few risks to the client during an external version. The fetus may return to the original position, but this is not a complication of the version. Anxiety may occur before the version but should decrease after the procedure is completed.

PTS: 1 DIF: Cognitive Level: Application REF: 311

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?

a.

Assess the infant for signs of trauma.

b.

Apply a cold pack to the infants scalp.

c.

Give the infant prophylactic antibiotics.

d.

Measure the circumference of the infants head.

ANS: A

Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessment.

PTS: 1 DIF: Cognitive Level: Application REF: 314

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

16. Nursing care before a cesarean birth should include:

a.

full perineal shave preparation.

b.

administering a clear oral antacid.

c.

injection of narcotic preoperative medications.

d.

straight catheterization to empty the bladder.

ANS: B

General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the client vomits and aspirates gastric contents during anesthesia. Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery. A narcotic at this point would put the fetus at high risk for respiratory distress. The catheterization should be indwelling to keep the bladder small during the surgery.

PTS: 1 DIF: Cognitive Level: Application REF: 318

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

17. A gravida 2, para 1 client is admitted to the labor and birth unit in labor. She states that she had a cesarean birth with her first pregnancy. The most critical information the nurse must obtain at this point is:

a.

the onset of contractions.

b.

her estimated date of birth.

c.

when the client ate last and what she consumed.

d.

the type of uterine incision with the first pregnancy.

ANS: D

A vertical incision creates a greater risk of uterine rupture in a subsequent labor than a transverse incision. The onset of labor is not the most important information that is needed at this point. This is important information to prepare for a fetus that may not be term. However, it is not the most critical question. If a cesarean birth is necessary this information is needed but not as critical as the type of previous incision.

PTS: 1 DIF: Cognitive Level: Understanding REF: 318

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. Which is an appropriate response to a clients comment that she is worried about having a cesarean birth?

a.

Dont worry. Everything will be okay.

b.

Clients commonly worry about surgery.

c.

What are your feelings about having a cesarean birth?

d.

I know youre worried, but this is a routine procedure.

ANS: C

Allowing the client to express her feelings is the most appropriate nursing response. The nurse should never provide the client with false reassurance or disregard her feelings. Saying to not worry is belittling the clients concerns and does not allow her to express her concerns. Saying clients commonly worry about surgery is closed-ended and belittling to the clients feelings. Acknowledging the worry but stating that the procedure is just routine is stating that the clients feelings are not important.

PTS: 1 DIF: Cognitive Level: Application REF: 321

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity

19. While assisting with a vacuum extraction birth, which should the nurse immediately report to the physician?

a.

Maternal pulse rate of 100 bpm

b.

Maternal blood pressure of 120/70 mm Hg

c.

Persistent fetal bradycardia below 100 bpm

d.

Decreased intensity of uterine contractions

ANS: C

Fetal bradycardia may indicate fetal distress and may require immediate intervention. Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm Hg is within expected norms for this stage of labor. Decreased intensity of uterine contractions indicates the birth is imminent at this point.

PTS: 1 DIF: Cognitive Level: Application REF: 314

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

20. To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement?

a.

Monitor her urinary output.

b.

Maintain an intravenous infusion at 1 mL/hr.

c.

Assess the abdominal dressings for drainage.

d.

Assess the uterus for firmness every 15 minutes.

ANS: D

Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.

PTS: 1 DIF: Cognitive Level: Application REF: 323

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

21. The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of a client. With which client should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?

a.

The client who has a Bishops score of 5

b.

The client who is at 42 weeks of gestation

c.

The client who had a previous low transverse cesarean birth

d.

The client who had previous surgery in the upper uterus

ANS: D

Prostaglandins are contraindicated in clients who have had a previous surgery in the upper uterus, such as a previous classic cesarean incision or extensive surgery for uterine fibroids. A side effect of prostaglandin administration is hyperstimulation of the uterus. A Bishops score of 5, 42 weeks of gestation, or a previous low transverse cesarean birth are not contraindications for cervical ripening.

PTS: 1 DIF: Cognitive Level: Analysis REF: 306

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

22. A vaginal exam for a laboring multipara client who is 42 weeks gestation reveals the following information: 4 cm, minimal effacement, 2 station. Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook?

a.

Vaginal dilation

b.

Client is a multipara

c.

Presenting part is at 2 station

d.

Gestational age

ANS: C

The fact that the presenting part is not engaged causes concern because there is increased risk of a prolapsed cord on artificial rupture of membranes (AROM). Vaginal dilation is adequate for attempt to rupture membranes. The fact that a client is a multipara is not a significant reason to affect clinical decision making with regard to AROM. Postdates of pregnancy may warrant a more aggressive approach to speed the labor and birth process.

PTS: 1 DIF: Cognitive Level: Analysis REF: 304

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

23. A client who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority?

a.

Increase rate of Pitocin infusion to help spread out contraction pattern.

b.

Place oxygen on client at 8 to 10 L/min via face mask and turn client to left side.

c.

Stop Pitocin infusion.

d.

Call physician to obtain an order for initiation of magnesium sulfate.

ANS: C

The client is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be called for additional orders.

PTS: 1 DIF: Cognitive Level: Analysis REF: 310

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

24. Which clinical finding indicates the use of vacuum extraction as a birth method?

a.

Mentum presentation of the fetus

b.

Presence of caput succedaneum

c.

Maternal exhaustion as a result of ineffective pushing during second stage of labor

d.

Physician preference

ANS: C

Vacuum extraction is used in place of forceps as an assistive method to help with the birth of the fetus. It is not used in nonvertex presentations. Mentum presentation is where the chin is the presenting part. Vacuum extraction should not be used in the presence of caput succedaneum (swelling) or in the presence of excessive molding.

PTS: 1 DIF: Cognitive Level: Application REF: 313

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

25. Which of the following factors would lead to an increased risk for a prolapsed cord to occur during an amniotomy?

a.

Presenting part engaged

b.

Postdated pregnancy

c.

Preterm pregnancy

d.

Term pregnancy

ANS: C

Prolapsed cord is more likely to occur when the presenting part is not engaged and the pregnancy is preterm because the fetus would be smaller and there would potentially be more amniotic fluid. If the presenting part is engaged and the pregnancy is at term or postdated, it is less likely that a prolapsed cord would occur.

PTS: 1 DIF: Cognitive Level: Analysis REF: 304

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

26. A client is being sent into the labor and birth unit for a serial induction of labor. The Bishops score is 7. What would the nurse anticipate as the sequence of treatment planned for this client?

a.

Administration of laminaria with EFM followed by amniotomy and oxytocin (Pitocin) infusion in a 12-hour period

b.

Amniotomy on the first day in conjunction with EFM followed by oxytocin (Pitocin) infusion on the following clinical day

c.

Administration of oxytocin (Pitocin) on the first day followed by amniotomy on the second clinical day

d.

Administration of laminaria with EFM on the first day followed by oxytocin (Pitocin) infusion on the second day and evaluation of progress; on the third day, continued oxytocin (Pitocin) infusion with amniotomy

ANS: D

A serial induction looks at a progressive treatment plan that is based on the best outcome, that of a successful birth. Because the Bishops score is 7, this indicates that certain conditions are not favorable for an induction. Therefore, the use of mechanical methods for cervical ripening maybe warranted. A serial induction is typically done over a 3-day period in which cervical ripening is followed by 2 days of Pitocin infusion, and on the last day an amniotomy is performed in conjunction with the infusion.

PTS: 1 DIF: Cognitive Level: Analysis REF: 308

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

27. On vaginal exam, the clients cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishops score for this client is:

a.

6.

b.

9.

c.

10.

d.

12.

ANS: B

On the Bishops scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70% effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9.

PTS: 1 DIF: Cognitive Level: Application REF: 307

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

28. Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents.

a.

Concurrent use of oxytocin and dinoprostone (Cervidil)

b.

Misoprostol (Cytotec) 25 mcg, followed in 4 hours by oxytocin induction in vaginal birth after cesarean section (VBAC) client

c.

Dinoprostone (Cervidil) 10 mg in place for 12 hours followed by oxytocin induction in 1 hour

d.

Maximum dose of dinoprostone (Prepidil) 2 mg/24 hr followed in 4 hours by oxytocin induction

ANS: C

Dinoprostone (Cervidil) in a 10-mg, time-release insert may be left in place for up to 12 hours and oxytocin induction can be safely started 1 hour after insert is removed. Oxytocin and cervical ripening agents cannot be administered at the same time. Misoprostol (Cytotec) is contraindicated in a women with previous cesarean. The maximum dose of dinoprostone (Prepidil) 1.5 mg/24 hr.

PTS: 1 DIF: Cognitive Level: Analysis REF: 308

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

29. When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately:

a.

stop oxytocin infusion.

b.

administer O2 at 8 TO 10 L/min.

c.

reposition client to left side-lying position.

d.

increase the rate of the primary nonadditive infusion.

ANS: A

Uterine hyperstimulation can reduce placental blood flow and decrease fetal oxygenation. Late decelerations are caused by uteroplacental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and increase fetal oxygenation. Administering O2, repositioning the client, and increasing the rate of the primary nonadditive infusion will not be effective until hyperstimulation is resolved.

PTS: 1 DIF: Cognitive Level: Application REF: 310

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

30. Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?

a.

Presence of newborn reflexes

b.

Symmetry of facial movements

c.

Caput and molding of the head

d.

Anterior and posterior fontanels

ANS: B

Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infants face.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

31. Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

a.

Anterior fontanel

b.

Coronal suture lines

c.

Posterior fontanel

d.

Biparietal diameter

ANS: C

The vacuum extractor is applied on the occipital bone and may create scalp edema at the application site. The posterior fontanel connects the occipital bone to the parietal bones. The anterior fontanel, coronal suture lines, and parietal bones are not part of the application area for a vacuum extractor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

32. In which client situation could an amniotomy be safely performed?

a.

G1 P0, 38 weeks gestation, 20% effaced, closed cervix

b.

G2 P1, 40 weeks gestation, with fetus in a breech presentation

c.

G2 P0, 39 weeks gestation, 70% effaced, cervix dilated 2 cm

d.

G3 P2, 41 weeks gestation, early labor complicated with hydramnios

ANS: C

The cervix must be partially open to allow the membranes to be ruptured. An amniotomy cannot be performed when the cervix is closed. Breech presentation would be delivered by cesarean section and membranes would be ruptured at birth. Rupturing the membranes in a client with hydramnios can result in abruptio placentae.

PTS: 1 DIF: Cognitive Level: Application REF: 307

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

33. When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurses best response would be to:

a.

stop the drip immediately.

b.

decrease the dose to 14 mU/min.

c.

reassess the patient at 5 minute intervals.

d.

reposition the patient to the left side-lying position.

ANS: B

In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation.

PTS: 1 DIF: Cognitive Level: Application REF: 309

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

34. Which breech presentation should the nurse recognize as being favorable for an external cephalic version?

a.

36-week gestation with low-lying placenta

b.

38-week gestation with one previous cesarean

c.

37-week gestation with fetal weight of 7 pounds

d.

40-week gestation with several uterine fibroids

ANS: C

An external cephalic version (changing the fetal presentation from breech to cephalic) is more successful when the pregnancy is at least 37 weeks and there is still adequate room and fluid to manipulate the fetus but prior to term or onset of labor. A low-lying placenta, previous cesarean birth, and uterine fibroids are contraindications for version.

PTS: 1 DIF: Cognitive Level: Analysis REF: 311

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

35. Following an external cephalic version, which assessment finding indicates a complication?

a.

Onset of irregular contractions

b.

Maternal blood pressure of 110/70 mm Hg

c.

Deceleration of FHR to 88 bpm

d.

Maternal pulse rate of 100 bpm

ANS: C

A serious risk of external cephalic version is that the fetus may become entangled in the umbilical cord, compressing its vessels and resulting in hypoxia. The onset of irregular contractions, maternal blood pressure of 110/70 mm Hg, and maternal pulse rate of 100 bpm are normal findings.

PTS: 1 DIF: Cognitive Level: Analysis REF: 311

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

36. In which of these situations should the nurse anticipate the use of forceps or vacuum extraction?

a.

Complete dilation for 2 hours at +2 station

b.

Complete dilation for 1 hour, transverse arrest at station +1

c.

Complete dilation for 3 hours, fetus at +3 station, onset of late deceleration

d.

Complete dilation for 1 hour, fetal descent from 0 station to + 1 in 1 hour

ANS: C

Forceps or vacuum extraction is considered if the second stage should be shortened for the well-being of the woman or fetus. Onset of late decelerations is an indication for an operative birth. With the fetus at +3 station, an outlet operative birth can be performed. Complete dilation for 2 hours at +2 station, complete dilation for 1 hour with a transverse arrest at station +1, and complete dilation for 1 hour with fetal descent from 0 station to +1 in 1 hour are situations in which client pushing and position changes would be used before operative intervention is indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

37. Which assessment finding is indicative of a major complication 1 hour following a forceps birth?

a.

Uterine fundus displaced at U + 1

b.

Complaints of vaginal and uterine pain

c.

Peripads showing moderate lochia rubra

d.

Increase in pulse rate from 90 to 110 bpm

ANS: D

Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. A displaced uterine fundus is mostly likely indicative of a full bladder. Vaginal pain may be present even when the vaginal mucosa is intact. Moderate lochia rubra is a common finding early in the postpartum period.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

38. A pregnant woman develops hypertension. The nurse monitors the clients blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with what complication?

a.

Abruptio placentae

b.

Cardiac abnormalities in the neonate

c.

Neonatal jaundice

d.

Reduced placental blood flow

ANS: D

Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.

PTS: 1 DIF: Cognitive Level: Understanding REF: 306

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

39. The pregnant client is admitted to the labor and birth unit for induction of labor. Which finding would allow the induction to continue as planned?

a.

Abruptio placentae

b.

Cephalopelvic disproportion

c.

Ripening of the cervix

d.

Umbilical cord prolapse

ANS: C

Procedures to ripen (soften) the cervix and make it more likely to dilate with the forces of labor are a common adjunct to induction. Most are done the day before the scheduled induction. Contraindications associated with induction may include cephalopelvic disproportion and umbilical cord prolapse. A cesarean section is indicated for abruptio placentae.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 307

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

40. The pregnant client expresses a desire to schedule birth during the babys fathers furlough from the Army. The nurse explains that prior to induction of labor, it is essential to determine which condition?

a.

Dilated cervix

b.

Fetal lung maturity

c.

Rupture of membranes

d.

Uterine hypertonia

ANS: B

Reassurance of fetal lung maturity is essential before elective procedures such as induction or cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction. Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor associated with induction of labor.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 306

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

41. The nurse monitors the client in labor for signs and symptoms of water intoxication. Which finding indicates that this may be occurring?

a.

Hypotension

b.

Rales and wheezes

c.

Slow shallow breathing

d.

Tachycardia

ANS: B

Signs and symptoms of water intoxication include headache, blurred vision, behavioral changes, increased blood pressure and respirations, decreased pulse rate, rales, wheezing, and coughing.

PTS: 1 DIF: Cognitive Level: Understanding REF: 311

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

42. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurses concern about this risk?

a.

Hypovolemia

b.

Iron deficiency anemia

c.

Prolonged use of oxytocin

d.

Uteroplacental insufficiency

ANS: C

Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.

PTS: 1 DIF: Cognitive Level: Understanding REF: 311

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

43. The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99 F [37.2 C]. What is the priority nursing action for this patient?

a.

Fetal acoustic stimulation

b.

Assess temperature every 2 hours

c.

Change absorption pads under her hips every 2 hours

d.

Review white blood cell count (WBC) drawn at admission

ANS: B

The womans temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38 C (100.4 F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 306

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

44. The labor nurse is providing care for a patient admitted for induction of labor at 38 weeks gestation. The patients Bishop score is 5, and an infusion of oxytocin (Pitocin) is initiated with orders that read as follows: mix 30 units of Pitocin in 500 mL of NS, increase the rate of infusion by 2 mL/hr every 15 to 60 minutes until a pattern of three contractions in 10 minutes is established. What is the priority nursing action for this patient?

a.

Increase the infusion of Pitocin every 30 to 60 minutes.

b.

Assess for changes in the patients cervix every 2 hours.

c.

Obtain a reactive nonstress test prior to starting the infusion.

d.

Determine the fetal heart rate baseline for 30 minutes prior to starting the infusion.

ANS: A

Cervical assessment estimates whether the cervix is favorable for induction. The Bishop scoring system is used to estimate cervical readiness for labor with five factorscervical dilation, effacement, consistency, position, and fetal station. Vaginal birth is more likely to result if the Bishop score is higher than 8. This patients Bishop score is low and she is at increased risk for an operative birth. Titration of Pitocin is at the judgment of the RN. A slower infusion of Pitocin allows more time for her body to adapt to the Pitocin and increases her potential for a nonoperative birth. Pitocin is a rapid-acting drug with an onset of 1 minute, duration of 30 minutes, and a half-life of 12 to 17 minutes. Cervical assessment is completed on an as-needed basis and is not scheduled. Assuring fetal well-being is important and can be determined by variability in the FHR baseline. A reactive nonstress test is not necessary prior to infusion. Establishing a baseline FHR prior to induction is a standard of care.

PTS: 1 DIF: Cognitive Level: Synthesizing REF: 307

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

45. A patient who is a 2-1-0-0-1 at 34 weeks gestation is interested in a vaginal birth after cesarean section (VBAC) and asks the nurse about this possibility. Which reason for her primary cesarean section would indicate to the nurse that the patient should be discouraged from pursuing this option?

a.

Transverse lie

b.

Prolapsed cord

c.

Placenta previa

d.

Cephalopelvic disproportion (CPD)

ANS: D

A prior cesarean birth alone is not an indication for another cesarean birth for most women. Many women will choose repeat cesarean rather than a trial of labor even if they are appropriate candidates for VBAC because of the small, but real, added risk for uterine rupture. For other women, trying to deliver their next baby vaginallywhether successful or notis important to them. Cephalopelvic disproportion is a condition in which fetal size exceeds the size of the pelvis. In cases of true CPD, the probability of the second fetus being smaller is slim and a repeat cesarean section is warranted. The remaining indications for the primary cesarean section do not relate to fetal size and a VBAC may be considered.

PTS: 1 DIF: Cognitive Level: Analysis REF: 317

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

46. Which adverse effects can be seen in response to administration of oxytocin (Pitocin) for induction of labor? (Select all that apply.)

a.

Maternal hyponatremia

b.

Uterine tachysystole

c.

Maternal hypotension

d.

Reassuring fetal heart pattern

e.

Decreased variability on fetal tracing

ANS: A, B, C

The administration of Pitocin can lead to a decrease in maternal serum sodium levels because of water intoxication. With regard to uterine effects, Pitocin can cause hyperstimulation or uterine tetany to occur, along with maternal hypotension. In terms of fetal response, Pitocin administration can lead to a nonreassuring fetal heart rate pattern manifested as bradycardia, tachycardia, and/or late decelerations and a decrease in variability, resulting in fetal compromise.

PTS: 1 DIF: Cognitive Level: Application REF: 309

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

47. Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)

a.

Fetal death

b.

Post-term pregnancy

c.

Rupture of membranes at or near term

d.

Convenience of the client or her health care provider

e.

Chorioamnionitis (inflammation of the amniotic sac)

ANS: A, B, C, E

Fetal death, post-term pregnancy, rupture of members, and chorioamnionitis are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for convenience of the client or her provider are not recommended; however, they have become common. Factors such as rapid labors and living a long distance from a health care facility may be a valid reason in such a circumstance.

PTS: 1 DIF: Cognitive Level: Application REF: 306

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

48. The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.)

a.

Assist the client to the bathroom.

b.

Position the client in a high Fowler position.

c.

Assess the uterus for excessive contractions.

d.

Monitor the fetal heart rate for at least 30 minutes.

ANS: C, D

The FHR should be monitored for at least 30 minutes for changes and the uterus should be assessed for excessive contractions. To reduce leakage, the woman should lie flat for 15 to 20 minutes after the gel form of prostaglandin is inserted. The client should not be assisted to the bathroom immediately or placed in a high Fowler position (head of bed up 90 degrees).

PTS: 1 DIF: Cognitive Level: Application REF: 307

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

49. A client is scheduled for an external cephalic version (ECV). Which should the nurse prepare to implement? (Select all that apply.)

a.

Initiation of an intravenous (IV) line

b.

Obtaining a baseline fetal monitoring pattern

c.

Administration of an oxytocin (Pitocin) infusion as prescribed

d.

Planning to observe the client and fetus for 1 hour after the procedure

e.

Administration of an Rh immunoglobulin after the procedure to Rh-positive clients

ANS: A, B, D

Preparation for an ECV includes starting an IV line for possible drug administration or fluid resuscitation if the FHR is not reassuring, fetal monitoring to obtain baseline values, and observing the client and fetus for 1 hour after the procedure. The nurse administers a tocolytic drug such as terbutaline not an oxytocin. Rh immunoglobulin is given only if the client is Rh-negative.

PTS: 1 DIF: Cognitive Level: Application REF: 311

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

50. A client asks the nurse, What can I do to avoid an episiotomy during birth? Which responses should the nurse give? (Select all that apply).

a.

Using the lithotomy position during pushing may be beneficial.

b.

Using prolonged breath-holding when pushing may help stretch the tissue.

c.

Beginning at 36 weeks, a daily 10-minute perineal massage may help stretch the tissue.

d.

Using an open glottis technique when pushing can promote gradual perineal stretching.

e.

Delaying pushing until the urge is felt can gradually distend the soft tissues of the pelvic floor.

ANS: C, D, E

Daily perineal massage and stretching by the woman from 36 weeks until birth has been shown to reduce the risk for perineal trauma during birth. Pushing with an open glottis technique rather than prolonged breath-holding when pushing promotes gradual perineal stretching. Delaying pushing until the urge is felt gradually distends the soft tissues of the pelvic floor. An upright position while pushing promotes gradual stretching of the womans perineum, not the lithotomy position.

PTS: 1 DIF: Cognitive Level: Application REF: 315

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

SHORT ANSWER

51. The nurse is determining a Bishop score on a client being admitted for induction of labor. The assessment on the client is 1 cm dilation, with 50 % effacement of the cervix, fetal station of 0, cervix consistency soft, and cervical position anterior. Which Bishop score should the nurse document? Record your answer as a whole number.

_______

ANS:

8

The Bishop system is used to estimate how easily a womans labor can be induced. Higher scores are associated with a greater likelihood of successful induction because her cervix has undergone prelabor changes, often called ripening. A cervix dilated to 1 cm = 1 point; a cervix effaced 50% = 1 point; fetal station of 0 = 2 points; soft cervix = 2 points; and anterior positioned cervix = 2 points; total points = 8.

PTS: 1 DIF: Cognitive Level: Application REF: 307

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

52. The health care provider has prescribed an initial rate of 6 mU/min of diluted Pitocin to be started to augment labor for a client having arrested labor. At which setting will the nurse set the infusion pump (in mL/hr) if the dilution of the Pitocin is 10 U of Pitocin in 1000 mL of 0.25 normal saline? Record your answer as a whole number.

_______ mL/hr

ANS:

36

10 units of Pitocin in 1000 mL of 0.25 normal saline = 10,000 mU/1000 mL (or 10 mU/1 mL). Cross-multiply to get 6 mU per X mL:

10:1::6:X = 10X = 6

X = 0.6 mL/min

Multiply by 60 minutes to get the amount infused per hour:

0.6 mL/min 60 min/hr = 36 mL/hr

PTS: 1 DIF: Cognitive Level: Application REF: 309

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

Leave a Reply