Chapter 19: Nursing Care during Obstetric Procedures My Nursing Test Banks

Chapter 19: Nursing Care during Obstetric Procedures

Test Bank

MULTIPLE CHOICE

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

a.

Spontaneous release of urine might contaminate the sterile field.

b.

An empty bladder provides more room in the pelvis.

c.

A sterile urine specimen is needed preoperatively.

d.

A Foley catheter prevents the membranes from spontaneously rupturing.

ANS: B

Feedback

A

Urine is sterile.

B

Catheterization provides room for the application of the forceps blades and limits bladder trauma.

C

A clean-catch urinalysis is usually sufficient for preoperative treatment.

D

The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 422

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Mild, intermittent perineal pain

b.

Edema and discoloration of the labia and perineum

c.

Lack of an episiotomy

d.

Lack of pain in the perineal area

ANS: B

Feedback

A

The pain with vaginal hematoma is severe and constant.

B

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.

C

An episiotomy is performed as the fetal head distends the perineum.

D

The pain associated with vaginal hematoma is severe.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 423

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

3. When positioning the Foley catheter before cesarean birth, the nurse knows that the catheter drainage tube and catheter bag should be

a.

Positioned on top of the patients leg

b.

Placed near the head of the table

c.

Clamped during the cesarean section

d.

Positioned at the foot of the surgeon under the sterile drapes

ANS: B

Feedback

A

The drain tube of the catheter should be positioned under her leg to promote drainage and to keep the catheter away from the operative area.

B

The anesthesia clinician must monitor urine output during the surgery.

C

Urinary output must be continuously monitored. An early sign of hypovolemia is a decreasing urinary output.

D

The surgeon might step on the drainage bag if the catheter was below the drapes, and no one could monitor the urine output.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 428 | Box 19-2

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

4. To provide safe care for the woman, the nurse understands that which condition is a contraindication for an amniotomy?

a.

Dilation less than 3 cm

b.

Cephalic presentation

c.

2 station

d.

Right occiput posterior position

ANS: C

Feedback

A

The dilation must be enough to determine labor.

B

The presenting part should be cephalic. Amniotomy is deferred if the presenting part is higher in the pelvis.

C

A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged.

D

This indicates a cephalic presentation, which is appropriate for an amniotomy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 413

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

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

a.

Past 42 weeks gestation

b.

Multiple fetuses

c.

Polyhydramnios

d.

History of long labors

ANS: A

Feedback

A

Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health.

B

Multiple fetuses overdistend the uterus, making induction of labor high risk.

C

Polyhydramnios overdistends the uterus, making induction of labor high risk.

D

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: Comprehension REF: p. 414

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

6. The standard of care for obstetrics dictates that an internal version might be used to manipulate the

a.

Fetus from a breech to a cephalic presentation before labor begins

b.

Fetus from a transverse lie to a longitudinal lie before cesarean birth

c.

Second twin from an oblique lie to a transverse lie before labor begins

d.

Second twin from a transverse lie to a breech presentation during vaginal birth

ANS: D

Feedback

A

For internal version to occur, the cervix needs to be completely dilated.

B

For internal version to occur, the cervix needs to be dilated.

C

Internal version is done to turn the second twin after the first twin is born.

D

Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 419

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

7. An indication for an episiotomy would be a woman who

a.

Has a routine vaginal birth

b.

Has fetal shoulder dystocia

c.

Is delivering a preterm infant

d.

Has a history of rapid deliveries

ANS: B

Feedback

A

Once routine for all vaginal deliveries, the perceived benefits of reducing pain and perineal tearing have not proven true.

B

An episiotomy is indicated in the situation where the shoulder of the fetus become lodged under the mother symphysis during birth.

C

A preterm infant is smaller and does not need as much space for delivery.

D

Rapid deliveries are not an indication for a mediolateral episiotomy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 424

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

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

a.

Trauma due to manipulation during delivery

b.

Tachypnea due to maternal anesthesia

c.

Prematurity due to miscalculation of gestation

d.

Tachycardia due to maternal narcotics

ANS: C

Feedback

A

There is reduced trauma with a cesarean birth.

B

Maternal anesthesia may cause respiratory distress.

C

Regardless of the many criteria used to determine gestational age, inadvertent preterm birth still occurs.

D

Maternal narcotics may cause respiratory distress.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 425

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

9. The nurse practicing in a labor setting knows that the woman most at risk for a uterine rupture is a gravida

a.

3 who has had two low-segment transverse cesarean births

b.

2 who had a low-segment vertical incision for delivery of a 10-pound infant

c.

5 who had two vaginal births and two cesarean births

d.

4 who has had all cesarean births

ANS: D

Feedback

A

Low-segment transverse cesarean scars do not predispose her to uterine rupture.

B

Low-segment incisions do not raise the risk of uterine ruptures.

C

This woman is not a high-risk candidate.

D

The risk of uterine rupture increases as the number of prior uterine incisions increases. More than 2 previous cesarean births places the woman at increased risk for uterine rupture.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 424

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

10. The nurse caring for a woman in labor understands that the primary risk associated with an amniotomy is

a.

Maternal infection

b.

Maternal hemorrhage

c.

Prolapse of the umbilical cord

d.

Separation of the placenta

ANS: C

Feedback

A

Infection is a risk of amniotomy, but not the primary concern.

B

Maternal hemorrhage is not associated with amniotomy.

C

When the membranes are ruptured, the umbilical cord may come downward with the flow of amniotic fluid and become trapped in front of the presenting part.

D

This may occur if the uterus is overdistended before the amniotomy, but it is not the major concern.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 412

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

11. Before the physician performs an external version, the nurse should expect an order for a

a.

Tocolytic drug

b.

Contraction stress test (CST)

c.

Local anesthetic

d.

Foley catheter

ANS: A

Feedback

A

A tocolytic drug will relax the uterus before and during version, making manipulation easier.

B

CST is used to determine the fetal response to stress.

C

A local anesthetic is not used with external version.

D

The bladder should be emptied, but catheterization is not necessary.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 419

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

12. 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

Feedback

A

With a wide pelvic outlet, vacuum extraction is not necessary.

B

With a mother who is exhausted will be unable to assist with the expulsion of the fetus.

C

With a rapid delivery, vacuum extraction is not necessary.

D

A station of 0 is too high for a vacuum extraction.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 420

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

13. The priority nursing intervention after an amniotomy is to

a.

Assess the color of the amniotic fluid.

b.

Change the patients gown.

c.

Estimate the amount of amniotic fluid.

d.

Assess the fetal heart rate.

ANS: D

Feedback

A

This is important, but not the top priority.

B

This is important for patient comfort, but it is not the top priority.

C

This is not a top priority for this patient.

D

The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred.

PTS: 1 DIF: Cognitive Level: Application REF: p. 413

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

14. For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?

a.

A woman in active labor with contractions every 31 minutes lasting 60 seconds each

b.

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

c.

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

d.

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

ANS: B

Feedback

A

Oxytocin may assist this womans contractions to become closer and more efficient.

B

This womans contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion.

C

There is an appropriate resting period between this womans contractions.

D

There is an appropriate resting period between this womans contractions for her stage of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 418

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

15. The priority nursing care associated with an oxytocin (Pitocin) infusion is

a.

Measuring urinary output

b.

Increasing infusion rate every 30 minutes

c.

Monitoring uterine response

d.

Evaluating cervical dilation

ANS: C

Feedback

A

Monitoring urinary output is important with Pitocin, but not the top priority.

B

The infusion rate may be increased, but only after proper assessment that it is appropriate.

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.

D

Monitoring labor progression is important, but not the top priority.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 418

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Maternal pulse rate of 100 bpm

b.

Fetal bradycardia persisting 10 minutes after the version

c.

Fetus returning to the original position

d.

Increased maternal anxiety after the version

ANS: B

Feedback

A

There are few risks to the woman during an external version.

B

Fetal bradycardia after a version may indicate that the umbilical cord has become compressed, and the fetus is having hypoxia.

C

The fetus may return to the original position, but this is not a complication of the version.

D

Anxiety may occur before the version but should decrease after the procedure is completed.

PTS: 1 DIF: Cognitive Level: Application REF: p. 419

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

17. Immediately after the forceps-assisted birth of an infant, the nurse should

a.

Assess the infant for signs of trauma.

b.

Give the infant prophylactic antibiotics.

c.

Apply a cold pack to the infants scalp.

d.

Measure the circumference of the infants head.

ANS: A

Feedback

A

Forceps delivery can result in local irritation, bruising, or lacerations of the fetal scalp.

B

Prophylactic antibiotics are not necessary with a forceps delivery.

C

This would put the infant at risk for cold stress and would be contraindicated.

D

Measuring the circumference of the head is part of the initial nursing assessment.

PTS: 1 DIF: Cognitive Level: Application REF: p. 422

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

18. When preparing a woman for a cesarean birth, the nurses care should include

a.

Injection of narcotic preoperative medications

b.

Full perineal shave preparation

c.

Straight catheterization to empty the bladder

d.

Administration of an oral antacid

ANS: D

Feedback

A

A narcotic at this point would put the fetus at high risk for respiratory distress.

B

Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery.

C

The catheterization should be indwelling in order to keep the bladder small during the surgery.

D

General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the woman vomits and aspirates gastric contents during anesthesia.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 426

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction?

a.

Amniotomy

b.

Intravenous Pitocin

c.

Transcervical catheter

d.

Vaginal insertion of prostaglandins

ANS: C

Feedback

A

Amniotomy is a surgical method of augmentation and induction.

B

Intravenous Pitocin is a medical method of induction.

C

Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include Laminaria tents, Dilapan and Lamicel.

D

Insertion of prostaglandins is a medical method of induction.

PTS: 1 DIF: Cognitive Level: Application REF: p. 416

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. What is an appropriate response to a womans comment that she is worried about having a cesarean birth?

a.

Dont worry. Everything will be okay.

b.

What are your feelings about having a cesarean birth?

c.

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

d.

Patients commonly worry about surgery.

ANS: B

Feedback

A

This answer is stating that the patients feelings are not important.

B

Allowing the patient to express her feelings is the most appropriate nursing response. The nurse should never provide the patient with false reassurance or disregard her feelings.

C

This is belittling the patients concerns and does not allow her to express her concerns.

D

This answer is close ended and belittling to the patients feelings.

PTS: 1 DIF: Cognitive Level: Application REF: p. 427

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

a.

Persistent fetal bradycardia below 100 bpm

b.

Maternal pulse rate of 100 bpm

c.

Maternal blood pressure of 120/70 mm Hg

d.

Decrease in intensity of uterine contractions

ANS: A

Feedback

A

Fetal bradycardia may indicate fetal distress and may require immediate intervention.

B

Maternal pulse rate may increase due to the pushing process.

C

This blood pressure is within expected norms for this stage of labor.

D

The birth is imminent at this point.

PTS: 1 DIF: Cognitive Level: Application REF: p. 422

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

22. To monitor for potential hemorrhage in the woman who has just had a cesarean birth, the recovery room nurse should

a.

Maintain an intravenous infusion at 100 mL/hr.

b.

Assess the abdominal dressings for drainage.

c.

Assess the uterus for firmness every 15 minutes.

d.

Monitor her urinary output.

ANS: C

Feedback

A

Maintaining proper fluid balance will not control hemorrhage.

B

This is an important assessment, but hemorrhage will first be noted vaginally.

C

Maintaining contraction of the uterus is important in controlling bleeding from the placental site.

D

This is an important assessment to prevent future hemorrhaging from occurring, but it is not the first priority assessment in the recovery room.

PTS: 1 DIF: Cognitive Level: Application REF: p. 430

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. 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 delivery unit is often asked to schedule patients 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.

Rupture of membranes at or near term

b.

Convenience of the woman or her physician

c.

Chorioamnionitis (inflammation of the amniotic sac)

d.

Postterm pregnancy

e.

Fetal death

ANS: A, C, D, E

Feedback

Correct

A, C, D, E. These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption.

Incorrect

B. Elective inductions for convenience of the woman 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: p. 414

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

2. Approximately 60% to 80% of women with one low transverse uterine incision from a previous cesarean birth may have a successful vaginal delivery. Recommendations from ACOG related to VBAC risks include (select all that apply)

a.

Immediate availability of the obstetric provider

b.

Delivery at a tertiary care center

c.

Availability of anesthesia personnel

d.

Personnel who can assist with the cesarean birth

e.

Use of misoprostol for cervical ripening

ANS: A, C, D

Feedback

Correct

A VBAC delivery should only be attempted with the obstetric provider in house, and anesthesia along with operative personnel readily available to perform a cesarean birth.

Incorrect

VBAC deliveries may be done in community hospitals if appropriate policies and guidelines for care are in place. Misoprostol administration is contraindicated in a patient with a previous uterine scar.

PTS: 1 DIF: Cognitive Level: Application REF: p. 424

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

TRUE/FALSE

1. As an adjunct to inductions, a number of procedures to ripen the cervix are employed. One of these methods is the vaginal administration of preparations using prostaglandins. Before administering this medication, the nurse should be aware that this class of drug is an appropriate choice for women who have had a prior cesarean birth. Is this statement true or false?

ANS: F

Prostaglandins are contraindicated in patients who have had a prior cesarean birth or other uterine surgery. A side effect of prostaglandin administration is hyperstimulation of the uterus. This may result in reduced uterine blood flow to the fetus, impaired gas exchange, and increased risk of uterine rupture. Prostaglandins should also be used with caution in women who have asthma, heart disease, glaucoma, or renal or hepatic dysfunction.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 415-416 | Table 19-2

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. The birth attendant evaluates whether labor and birth are safer for the woman and her fetus than continuing the pregnancy. The Bishop Scoring System remains a popular tool to assist in this task. Is this statement true or false?

ANS: T

The Bishop score uses 5 factors to determine readiness for labor (dilation, effacement, consistency, position, and fetal station). The likelihood of a vaginal birth is similar to that of spontaneous labor if the score is greater than 8.

PTS: 1 DIF: Cognitive Level: Application REF: p. 414 | Table 19-1

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

COMPLETION

1. A popular preinduction cervical ripening agent that is Food and Drug Administration (FDA) approved for the treatment of peptic ulcers is __________.

ANS:

misoprostol

Cytotec

This synthetic prostaglandin tablet is used primarily for the prevention of peptic ulcers. Because of its low cost, stability, and ease of use, many facilities use this medication for cervical ripening and the induction of labor. The manufacturer does not intend to seek FDA approval for other indications; however, ACOG supports its use for these purposes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 415

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. The nurse is caring for a woman in labor at 39 weeks and 5 days of gestation. Her labor progress has slowed due to poor contractions. After discussion with the provider, a decision has been made that she is a good candidate for ___________ of labor.

ANS:

augmentation

Augmentation of labor with oxytocin is considered when labor has begun spontaneously but progress has slowed or stopped. The rate of oxytocin may be lower than that of an induction.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 414

OBJ: Nursing Process: Planning and Implementation

MSC: Client Needs: Physiologic Integrity

Leave a Reply